Lottie Reid

Birmingham Heartlands Hospital 
Bordesley Green East 
Birmingham 
B9 5SS 

Tel: 0121 424 2320 

AJC/TB/LMcL 

20 August 2015 

Ms Margaret Jones 
HM Assistant Coroner for Birmingham and Solihull 
50 Newton Street 
Birmingham 

Dear Ms Jones,  

Inquest into the death of Mrs Lottie Reid – Report to Prevent Future Deaths  

I write in response to the Regulation 28 Report made by you following your investigation and inquest 
into  the  death  of  Mrs  Lottie Reid on  9 and  24  June  2015  and  your  letter  to  Mr  Andrew  Foster,  Chief 
Executive.  

I am responding in my capacity as the Trust Executive Medical Director & Deputy Chief Executive. 

The  Heart  of  England  NHS  Foundation  Trust  (the  "Trust")  has  carefully  considered  the  important 
matters raised by you at the inquest and I set out the Trust's response below: 

1.  That  following  discharge  from Good  Hope Hospital  to  Perry  Trees Intermediate  Care Centre 
the  Printed  Electronic  Prescribing  Medication  Admin  Chart  ("PEPMAC")  did  not  mirror  the 
medication referred to in the Discharge Letter and Prescription.  

2.  There  did not  appear  to be  a protocol in place whereby  such  discrepancies  could easily be 
checked and this appeared to be especially difficult to do at weekends.  

The  Trust  is  aware  of  the  importance  of  ensuring  that  there  is  clarity  in  relation  to  the  medications 
prescribed whilst in hospital, and on discharge into the community or to an intermediate care facility. It 
is  for  this  reason  that  the  Trust  has  a  procedure  for  discharging  patients  into  intermediate  care  (the 
"Intermediate  Care  Procedure").  Enclosed  is  a  copy  of  the  Intermediate  Care  Procedure  for  your 
consideration.  

As you are aware, the medical staff are not permanently present at the intermediate care facility, which 
clearly  impacts  on  their  availability  to  prescribe  a  given  medicine  (although  it  is  common  practice  for 
intermediate care facilities to be staffed in this way).  Without medication being appropriately prescribed 
and documented on a Medicines Administration Chart ("MAC") (also known as a PEPMAC), nurses are 
unable to administer the medication.  

I  understand  that  the  Trust  Intermediate  Care  Procedure  requires  patients  to  be  discharged  to  an 
intermediate  care  facility  with  a  MAC  chart.  The  MAC  chart  should  be  reviewed  by  the  doctor  at  the 
same time as the To-Take-Out ("TTO") is written up to reflect the medicines required at discharge as 
opposed to the medicines being taken during admission.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Regrettably,  in  Mrs  Reid's  case  when  she  was  discharged  into  the  intermediate  care  facility,  Perry 
Trees, there was a discrepancy between the PEPMAC and the discharge letter and prescription. 

In  responding  to  your  Regulation  28  Report,  we  have  sought  the  views  of  the  senior  responsible 
clinician  based  at  Good  Hope  Hospital, 
  (Associate  Medical  Director)  and  the  Clinical 
Director and Chief Pharmacist Tania Carruthers.     

In order that the risk of future events can be reduced the following steps have been taken by the Trust:   

1.  On  reflection,  it  was  felt  that  a  lack  of  staff  awareness  of  the  Intermediate  Care  Procedure  was  a 
contributory factor. To ensure this procedure is followed in future, the Trust is sending a clinical alert to 
all wards at Good Hope Hospital by the end of August. By way of context, it should be noted that whilst 
staff awareness of the procedure was a factor, it appears that this was the first incident of its kind at 
one of our intermediate care facilities (although that in no way minimises the seriousness of this case).   

2. The Trust is amending the nursing discharge checklist to include a reminder to check the PEPMAC.  

In  addition  to  strengthening  the  processes  as  described  above,  we  consider  that  this  case  is  an 
opportunity to improve to the discharge process and the documentation in particular:    

3.  The  Trust  is  in  the  process  of  improving  the  discharge  documentation  (known  as  yellow  cards), 
which is currently used by clinicians discharging palliative care patients to other carers. This procedure 
requires  the  treating  clinician  to  write  and  sign  a  separate  document  which  details  the  patient's 
prescribed medication, which is then used by the treating clinicians on discharge.  

This process will reduce the risk of inconsistency in the discharge documents for the patient, as there 
will  only  be  one  document  that  the  clinicians  will  refer  to  on  discharge.  The  template  will  be 
standardised to ensure it contains the optimal information for safe prescribing and administration.  

Once the new documentation has been approved through our governance processes, it will be piloted 
within  palliative  care.  Subject  to  feedback  from  the  community  staff,  a  final  decision  as  to  the 
appropriateness  of  implementing this  process for  patients  being  discharged into  an  intermediate care 
facility will be made. It is likely that this decision will be made in the next six months, and will be based 
on clarity of the prescribing and a review of any reported incidents.  

4. The dissemination of information about the Intermediate Care Procedure to all wards at Good Hope 
Hospital  will  address  the  issues  raised  in  this  case.  However,  as  an  additional  step,  should  any 
inconsistencies  arise  in  future  the  staff  at  the  intermediate  care  facility  can  check  the  patient's 
prescribed medication by telephoning the discharging ward directly.  

5. In addition, discharge letters (excluding paediatrics and cancer services) include a statement at  the 
bottom that if there are any questions or concerns about the discharge medication they should call the 
pharmacy Medicines Helpline (0121 424 4682).  

6. To strengthen the current pharmacy processes, when available, MAC charts and TTOs are checked 
for  discrepancies.  As  part  of  our  response,  the  incident  was  discussed  with  the  pharmacist  involved. 
The Chief Pharmacist has also reminded all of her pharmacists about the importance of this issue. The 
Chief Pharmacist is also reviewing existing SOPs to ensure they are robust and fit for purpose. 

Finally, in sad situations such as this, it is important that the family of Mrs Reid are made aware of the 
steps that we are taking to reduce the risk of future events.  

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 If I can be of any further assistance, please do not hesitate to contact me.  

Best wishes. 

Yours sincerely, 

Deputy CEO and Executive Medical Director 

Encs 

cc 

 Deputy Medical Director for Clinical Performance 

Rachael Blackburn, Acting Deputy Director of Governance