Dear Mr Horsley Re: Miss Courtney Mills, DoB 12/06/2002 42 Forton Road, Gosport, Hants, PO12 4TH We received your letter on 13.5.2014 regarding a Regulation 28 Report on Courtney Jordan Mills_ An inquest had been held on 24.3.2014 into the death of Courtney Mills and believe that copies of computer records of Courtney'$ GP notes were sent to you on 28.10.2013. Courtney' s registered GP was) who attended the inquest andat that time provided information about matters of concern listed on Section 5 of Regulation 28_ has now left the Practice and is currently having a year of adoption leave My involvement was as follows: 15th March 2013: received a telephone call from the pharmacist regarding a prescription for Clonidine tablets which had been issued two days earlier b notes from the 13" March when she was doing that prescription state, "Medication requested: New meds from hospital so script done" assume from this thatl Jhad done the prescription based on the hospital's recommendation although cannot find a hospital discharge letter from that time in Courtney's notes. The pharmacist was querying the prescription as Courtney had been on Clonidine liquid in hospital and mum had told her that Courtney could not swallow Clonidine tablets. The pharmacist was concerned a5 she was unable to get Clonidine liquid immediately as it is available only as a special order and would take five days or so to arrive Courtney had completely run out of her Clonidine liquid and it was Friday afternoon, so the options were very limited: Friday

rang the paediatrician on call at Southampton General Hospital, as had come into the surgery late on afternoon to try and resolve this. The paediatrician on call discussed Courtney with Courtney' s consultant at Southampton General and they decided that it was not ideal to crush the tablets, and they suggested instead Increasing her Chloral Hydrate solution instead of having the Clonidine: were due to see Courtney on the following Monday so thev planned to give Clonidine liquid from the hospital pharmacy at that appointment; They also suggested that] could go across to Southampton to a new supply them straightaway but she was unable to get to Southampton to do this_ was next involved on the 12th April 2013 also a had come to the surgery that afternoon, again needing a prescription of Clonidine solution: Mum said that she had a new discharge letter from Southampton Hospital which she had not yet dropped into the surgery but she said that it instructed that Courtney should take an increased dose of Clonidine solution. At that pointh Itold me that they had enough Clonidine solution to last for another week and when we' contacted the pharmacy they again said that it would take at least a week to get this medication: At that time mum said she would ask at the hospital appointment at the end of the month whether any sort of patches could be used instead of Clonidine solution: supplied a handwritten prescription for a thirty days supply of Clonidine oral solution: This product is not available on the computer formulary as it is a special order and has to be specially ordered in by the pharmacy: Because of the difficulties in obtaining Clonidine solution, Wrote to the consultant paediatric neurologist in Southampton, on 15.04.2013 to ask for some clarification about the medication, and to explain the difficulties we were having obtaining the medication in the community: tthen spoke to on the telenhone on 18.04.2013 regarding the Clonidine prescription. They discussed the transdermal option butl (felt there were medico-legal issues as it was off licence_ Ifelt that it was more appropriate that Southampton carried on supplying the medication and explained the difficulties td these being that there was a week's minimum, in sourcing Clonidine solution in the community and it was also impossible to issue it via the computer said that she would discuss the matter further with the hospital pharmacy: can completely understand how frustrating this has been. It may not have been obvious how much hard work had gone on behind the scenes to try and obtain and find an answer to the problem of getting Clonidine solution. It was always readily available at Southampton hospital pharmacy but was never easily available in the community: would respectfully suggest that the delay in obtaining the medication was not due to communication difficulties between ourselves and the hospital: believe that it was because the medication simply was not available in the community except with week's notice to the pharmacy: The GP'$ at Waterside Surgery have spent some considerable time trying to sort this out with the pharmacies and with Southampton. We have clearly documented in Courtneys notes the many occasions on which this has happened:

Dear Mr Horsley Courtney_ Jordan Mlls 1063/13 (DOB 12/06/2002 DOD 19/04/2013 refer to your letter with which you enclosed Regulation 28 Report dated 12 May 2014. note that this report was also sent to the Practice Manager of the Waterside Medical Centre in Gosport: As you will of course recall; Consultant Paediatrician, gave evidence at the Inquest and have therefore sought his input into this response as well as from our Pharmacy Department: The report states that there had been history of delay in Courtney obtaining her medication (Clonidine) due to communication difficulties between the hospital and the GP surgery and you have asked that action be taken to prevent future deaths understand from that the Clonidine was not in fact prescribed by Portsmouth Hospitals NHS Trust and our Pharmacy Department have also confirmed that we have no evidence to suggest that Queen Alexandra Hospital were approached for a supply of the although had we been approached, we would have supplied it: In past situations like these, where community pharmacists have' had trouble getting hold of non-routine medicines , the patients family have contacted our Children's Assessment Unit (CAU) who have arranged for it to be prescribed by a doctor here and then we have dispensed it from the QAH pharmacy: This is a situation that we are used to and we would have done this in this case However, had CAU been asked may have had problem verifying the usual dosage, in which case we would have had to contact Southampton prior to writing the prescription: drug, they

2 am aware that maintaining correct medication when patients leave hospital is significant problem across the NHS as it involves co-ordination between hospitals, GP practices, pharmacy and patients themselves, often with an important medication change made as result of acute illness While doctors clearly share responsibility for this, Pharmacists may be best placed to ensure safe processes around this. In the first instance, and if you feel that this issue needs to be considered on a national level, would suggest that the Royal Pharmaceutical Society may be the best body to contact_ In the circumstances_ should be grateful if you could confirm that this response is sufficient and that you do not require Portsmouth Hospitals NHS Trust to take any further steps in respect of your report: With best wishes