Rosemary Oladejo

Central and North West London INHS|

NHS Foundation Trust

Mr C Inyama

Chief Coroner for West London
Coroner’s Office

25 Bagleys Lane

Fulham

SW6 20A
17 June 2014

Dear Mr Inyama

| refer to an email from HR ciated 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’s 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
you on that particular point. We are satisfied that in this case our communication systems were
effective. However as 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 the
importance of good 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.

Claire Murdoch
Chief Executive

Trust Headquarters, 1st Floor, Stephenson House, 75 Hampstead Road, London, NW1 2PL
Telephone: 020 3214 5700 Fax: 020 3214 5701 www.cnwl.org

Hillingdon
Clinical Commissioning Group

Kirk House

97-109 High Street
Yiewsley
Middlesex

UB? 7HJ

Tel: 01895 452006
Fax: 01895 488166

16" June 2014 Nitto Awww hillinadoneeg nhs. uk

Mr Chinyere Inyama

West London Coroners Court
25 Bagleys Lane

Fulham

London

SW6 20A

Following receipt of the regulation 28 report sent to Hillingdon CCG and Central North West London
Trust (CNWL) dated 22"¢ April, arising from the inquest into the death of Tanya Oladejo, please find
the Hillingdon CCG response to the concerns outlined the report.

Dear Mr Chinyere Inyama

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

e Responsible clinician not made aware of the unilateral titration of amitriptyline, so unaware a
drug prescribed as a 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
fo identify whether the case was reported as a Serious incident by the Trust. The investigation
report from CNWL was requested, which was received by the Head of Quality and Safety on 18”
May 2013.

The initial Management report identified that Tanya 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

Hillingdon
Clinical Commissioning Group

Psychology appointments, on 7" and 14" 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 a voice message. After the second DNA, a letter was sent to Tanya. Tanya
also had an outpatient appointment booked on the 2" May 2013.

The Initial Management Report did not identify hat non-compliance with the DNA policy played a
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 Trust regarding its DNA policy.

On receiving the Initia! Management Report a view was sought from the HCCG mental health
commissioner, the clinical leads for NWL Mental Health Programme Board, and Hillingdon CCG
medicines management lead on 19" May. 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. A response from the HCCG Head of Medicines Management was received on
27th May 2014.

The response confirmed that Tanya was being prescribed the SSRI anti-depressant drug 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 patient’s presentation. Occasionally the GP was prescribing a second
anti-depressant drug in addition to the sertraline. This was amitriptyline, a 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, ail clinicians would
normally review the full list of medications prescribed for patients.

However, in this case, a 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
drug. 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

Hillingdon
Clinical Commissioning Group

setting to another it is essential that accurate and reliable information about the patient's medication
is transferred at the same time.

This enables healthcare professionals responsible for the care to be able to match-up the patient’s
previous medication list with their current medication list; thereby enabling timely, informed decisions
about the next stage in the patient's medicines management joumey.

May 28" 2013 these recommendations were shared with the Medicines Management Teams in
Hillingdon, and subsequently in Brent and Harrow CCGs. BHH (Hillingdon, Brent and Harrow) have
a shared quality and clinical governance structure). This learning has subsequently been shared
with the CCG governing body lead for prescribing, and will be communicated with Hillingdon GPs via
the weekly GP newsletter in the week commencing 16" June.

Future Actions Proposed
1. Review the current processes for recording medications in the different sectors by August
2014

2. Review the current processes for communicating this information from one sector fo another
by August 2014
3. Discuss with the Pharmacy Leads in CNWL and the Hillingdon Hospitals Trust the possibility

of developing one standard letter or form fer use across all sectors in July 2014

4. Ensure our practice pharmacists review and improve medicines reconciliation processes in
practices starting in July 2014 and on-going thereafter.

| hope this addressed the concerns raised satisfactorily but please do contact me again if there are
any further queries or actions required.

Yours sincerely

Hillingdon CCG