Dear Mr Chinyere Inyama Following receipt of the regulation 28 report sent to Hillingdon CCG and Central North West London Trust (CNWL) dated April, arising the inquest into the death of Tanya Oladejo, please find the Hillingdon CCG response to the concerns outlined the report Summary of concerns outlined: Responsible clinician making adjustments to the prescribed medication regime , including allowing the GP to vary the amount of sertraline according to the patient' s presentation The GP on occasion titrated the amount of amitriptyline prescribed according to the patients presentation Responsible clinician not made aware of the unilateral titration of amitriptyline , SO unaware a drug prescribed as sleeping draft was being prescribed and labelled to be taken in the morning: Lack of adequate communication between the responsible clinician and GP practice regarding medication. Timetable of actions taken The Head of Quality and Safety North West London Commissioning Support Unit contacted CNWL to identify whether the case was reported as Serious Incident by the Trust The investigation repor from CNWL was requested, which was received by the Head of Quality and Safety 0gat8n
2013. The Initial Management report identified that was seen in CNWL outpatient clinic and was receiving weekly psychological input. Tanya's last contact with CNWL was on 28 Feb 2013 when she was seen in her psychology appointment Tanya had failed to attend her 2 subsequent Group 22nd from May Tanya

NHS Hillingdon Clinical Commissioning Psychology appointments, on 7th and 14th March. The Trainee Psychologist reported the matter after her first DNA with psychology: Tanya was contacted by text message as there was no facility on her phone to leave voice message After the second DNA a letter was sent to Tanya. Tanya also had an outpatient appointment booked on the 2nd
2013. The Initial Management Report did not hat non-compliance with the DNA policy played part in Tanya's death, as all relevant paperwork was completed The Head of Quality and Risk (NWL CSU) confirmed that the Initial Management Report of 22nd March 2013 contained no recommendations for the regarding its DNA policy. On receiving the Initial Management Report a view was sought from the HCCG mental health commissioner; the clinical leads for NWL Mental Health Programme Board, ad Hillingdon CCG medicines management lead on 19th It was agreed to explore the time frame and process for notification of any change of medication and follow-up sessions of treatment between GPs and CNWL lead clinician. response from the HCCG Head of Medicines Management was received on 27th May 2014. The response confirmed that was prescribed the SSRI anti-depressant sertraline by the CNWL Responsible Clinician The ongoing prescribing of sertraline was provided by the patient's GP who adjusted the dose of sertraline, as authorised by the Responsible Clinician in Outpatients, according to the patients presentation. Occasionally the GP Was prescribing a second anti-depressant drug in addition to the sertraline. This was amitriptyline, tricyclic antidepressant This means that sometimes, the patient was taking 2 lots of anti-depressants. SSRIs and Tricyclic anti-depressants have both been linked with suicidal behaviour. The Responsible Clinician and the GP were both adjusting the dosages of these drugs according to the patient's presentation. Before prescribing or adjusting dosages of any drugs, all clinicians would normally review the full list of medications prescribed for patients. However; in this case, full list of medicines does not appear to have been available as the Responsible Clinician did not know the GP was occasionally prescribing a second anti-depressant For some reason, the patient's medication record did not show this. The process by which the GP and Outpatients departments in CNWL communicate needs to be more robust As is usual in other areas of communication, patients' full list of medications should follow the patient's journey between different sectors of the health service, so that all prescribers in any setting can make prescribing decisions with the full knowledge of all medicines the patients is currently taking: To avoid further such incidents, all prescribers should implement guidance from NICE, NPA (National Prescribing Centre) and the NPSA (National Patient Safety Agency) on medicines reconciliation. This is a process which ensures that all medicines taken by patients are documented on admission and at each transfer of care. Every time a patient is transferred from one healthcare 2 Group May identify Trust May: Tanya being drug drug:

[HS Hillingdon Clinical Commissioning setting to another it is essential that accurate and reliable information about the patient s is transferred at the same time medication This enables healthcare professionals responsible for the care to be able to match-up the patients Ptevious medication list with their current medication list; thereby enabling timely, informed deciseons about the next stage in the patients medicines management jourey: 28"h 2013 these recommendations were shared with the Medicines Hillingdon, and subsequently in Brent and Harrow CCGs. BHH Management in a shared (Hillingdon; Brent and Harrow) have quality and clinical governance structure). learning has subsequently been shared with the CCG governing body lead for prescribing; and will be communicated with the weekly GP newsletter in the week 16th Hillingdon GPs via commencing June. Future Actions Proposed Review the current processes for recording medications in the different sectors 2014 by August 2 Review the current processes for communicating this information from one sector to another by August 2014 3_ Discuss with the Pharmacy Leads in CNWL and the Hillingdon Hospitals Trust the of developing one standard letter or form for use across algsectorosnijaly 2014 possibility Ensure our practice pharmacists review and improve medicines practices starting in 2014 and on-going thereafter reconciliation processes in hoperthes addressed the concerns raised satisfactorily but please do contact me again if there any further queries or actions required. are

Dear Mr Inyama refer to an email from dated 23 April 2014, enclosing a Regulation 28 report relating to the inquest of Tanya Rosemary Marion Oladejo. In that report; which was also sent to the CEO of Hillingdon Clinical Commissioning Group, you recommended that action should be taken to prevent future deaths and felt that the CEOs of both organisations had the power to take such action: This related to the 'worrying lack of adequate communication between the GP Practice and the responsible (CNWL) clinician about medication prescribed to assist in controlling Tanya's condition"_ This was, of course, a tragic death and we were keen to identify if there was any specific action that our staff should have taken in relation to the issue raised in the above recommendation. To that end we reviewed the case, the evidence given at the Inquest and sought advice from the Trust'$ solicitor, who represented us at the Inquest must advise you that in our view the issue of particular concern in this case was one that related to inadequate communication by the GP to our clinician and it is appropriate for the CCG to respond to vou on that particular point_ are satisfied that in this case our communication systems were effective: However a5 an organisation we are always keen to learn from any incidents that occur and we feel it would be helpful to ensure that staff across our organisation are reminded of importance of communication: One of the means we have for disseminating such lessons is a Clinical Risk Alert: We will be circulating an alert in the next few weeks which will include reference to this case (in an anonymised form): should be happy to forward a copy to you if you would find that of interest, will also be taking this for learning purposes to the Mental Health Partnership Board, which comprises the 8 CCGs and 2 mental health trusts in North West London, in order to highlight the importance of the communication lessons from this case. trust this will be sufficient assurance that we have considered your recommendation and are taking action accordingly. Do please let me know if you require any further information on this matter. Yours sincerelv Claire Murdoch Chief Executive Trust Headquarters , 1st Floor; Stephenson House, 75 Hampstead Road, London, NW1 2PL Telephone: 020 3214 5700 Fax: 020 3214 5701

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