Darren Carrington

Brighton and  Sussex 
University Hospitals 
NHS Trust 

Brighton and Sussex University Hospitals  NHS Trust 
Trust Headquarters 
Royal  Sussex County Hospital 
Eastern  Road 
Brighton 
BN25BE 

30 October 2018 

Miss Veronica  Hamilton-Deeley 
Her Majesty's Senior Coroner 
for the City of Brighton &Hove 
The Coroner's Office 
Woodvale 
Lewes Road 
Brighton 
BN23QB 

Dear Miss Hamilton-Deeley 

Mr Darren James Carrington deceased 

Thank you for your letter dated  15 June 2018 which  I know was acknowledged  by my colleague 

 on  18 June. 

I appreciate you  did not request a response,  other than to acknowledge receipt of your letter, 
but I felt.it was important to update you  on  the issues you  raised,  and  I apologise for the  length 
of time this has taken. 

I am  very sorry that Mr Carrington's GP,  Sussex Partnership NHS Foundation Trust and 
Pavilions did  not receive adequate information concerning the details of Mr Carrington's mixed 
overdose and  accept that this does not reflect good  continuity of care.  I can  confirm that this has 
been fed  back to 

,  Clinical Director for Emergency and Acute Medicine and  to 

,  Consultant and  Governance Lead for Emergency Medicine. 

have discussed these issues with  all  medical staff as part of the  Emergency Department regular 
governance meetings to highlight the issues that arose from  Mr Carrington's attendances and 
the importance of ensuring that discharge letters contain sufficient detail. 

With  regard  to sending discharge summaries I agree that these should  ideally be sent by  e-mail 
on the same day of the patient's discharge.  However, this is  a major project for the Trust and 
there is a considerable amount of work to  be done on  process and  system testing  before this 
can  be implemented. We are currently focused  on  roll-out of the new Medway Patient 
Administration System and  our hope is to  implement systems within the next 12 months to allow 
discharge letters and summaries to be sent electronically to GPs and other partner 
organisations as required. 

If you  need  any further information  please do not hesitate to contact me. 

 
 
 
 
 
 
 I would  also like to pass on  my condolences to  Mr Carrington's family and friends for their sad 
loss. 

Yours sincerely 

Chief Medical  Officer and  Deputy Chief Executive

Comrnissioning Amance 

Hove Town  Hall
Norton Road 
Hove
BN3  4AH

- 1 

Veronica Hamilton-Deeley DL,  LL.B. 
Her Majesty's Senior Coroner for the  City of 
Brighton & Hove 
The Coroner's Office 
Woodvale Road 
Brighton 
BN23QB 

27 July 2018 

Dear Veronica Hamilton-Deeley, 

The Late Mr Darren James CARRINGTON 

Thank  you. for  your  recent  letter  enclosing  a  Regulation  28  request  following  the  death  of 
Darren  James  Carrington. 
I  was  very  sorry  to  hear  of  his  death  and  I  hope  the  following 
information helps somewhat. 

In  preparing  my  request,  I  have  spoken  with 
,  the  CCG  Medication  Management 
and  Quality  and  Safety  colleagues,  as  well  as  clinical  and  senior  admin  colleagues  from  a 
linked GP Practice - who have provided support and  advice to 

 and his team. 

I  have  been  encouraged  by 
offer  to  participate  in 
correspondence) is welcome and  I am confident will be of benefit to all of primary care. 

  open  and  constructive  response  to  events,  and  his 
in  previous 

the  CCGs  Task  and  Finish  Group  (as  proposed 

Brighton  and  Hove  has  above  average  numbers  of deaths  relating  to  misuse  of  prescribed 
medication. Alcohol  and  recreational drug misuse are often factors.  As  you  have outlined,  the 
Primary  Care  workforce  has  changed,  with  more  salaried,  locum  and  less  than  full-time 
posts.  Those signing prescriptions are less likely to have personal  knowledge of patients and 
it is essential to have robust processes in  place to ensure patient safety. 

When  Practices  acquire  new  IT  systems  or  upgrades,  initial  training  is  often  limited.  It  is 
important  that  staff  have  access  to  ongoing  structured  training  around  optimal  use  of  the 
system,  as in-house digital knowledge can be variable. 

 
 
 
 
 Patients  are  increasingly  obtaining  medication  directly via  the  Internet.  My  understanding  is 
that this was the case with  DC.  Questioning if patients  are obtaining medication via  this  route 
needs to  become a standard part of the consultation. 

I can  confirm  that the following  changes  have been  implemented at North  Laine Surgery via  a 
Practice Meeting attended by all  staff: -

•  All  reports of patient self-harm are now circulated to clinical staff. 
•  Review of best practice for coding self-harm. 
• 

Increased awareness of potential significance of frequent requests for apparently small 
quantities of medication. 

•  All  patients receiving Zopiclone have had their records  audited.  No evidence has been 
found  of other patients over ordering.  Quantities of medication  have  been  reviewed  as 
appropriate. 

•  Records of all  patients  receiving  weekly prescriptions  have  been  reviewed  and access 

to on-line requests have been removed. 

•  Records  of all  patients  receiving  prescriptions  for  CDs  or drugs  of potential  abuse  or 

dependency, have been reviewed and access to online requests removed. 

•  Arrangements  have  been  made  to  ensure  administrative  and  clinical  staff  have 

adequate,  protected time to manage prescription requests. 

•  Ongoing  discussions  with  linked  Practice  around  sharing  high  risk  medication  review 

protocol. 

•  Computer  settings  changed  with  a  view  to  lower  thresholds  for  flagging  up  early 
ordering  of scripts  and  increased awareness around  the  potential  significance of these 
and  other alerts. 

•  The  importance of appropriate 'maximum  number 'of repeats  authorised with  a view to 

triggering a clinical review of cases. 

Our  Medication  Management  team  are  providing  ongoing  support.  In  particular,  around 
embedding  The  High  Risk  Drug  review  protocol  mentioned  above,  as  well  as  ensuring  that 
the new Practice Repeat Prescribing Policy covers current best practice. 

I am  confident that the  measures outlined will  significantly reduce the chance of future related 
patient  harm  at  North  Laine  Surgery.  It  is  however,  essential  that  the  learning  is  shared 
across  the  city.  The Task and  Finish  Group's  membership will  include  Community Pharmacy 
Representatives,  CCG  digital  staff,  Practice  Managers as well  as  Primary care Clinicians with 
a view to  ensuring maximal learning from  this case is embedded across the city. 

You  raise  the  important  issue  to  what  extent  Community  Pharmacists  provide  an  additional 
level  of  safety.  Representatives  of  the  Local  Pharmaceutical  Committee  have  agreed  to 
attend  the  Task  and  Finish  Group  during  which  we  will  highlight this  role  and  the  importance 
of a joint approach. 

 Finally,  the  Practice  are  in  the  process  of completing  a  serious  incident  investigation  report 
that will  be  submitted  to NHSE.  Any further learning from  this  will  be  disseminated  locally via 
the Task and  Finish Group. 

Please do not hesitate to contact me if you  require any further assistance. 

Kind  regards, 

Clinical Chair 
Brighton and Hove Clinical Commissioning Group

~C !E  VI !E ltf i 

2 

-

-- - j  North  Laine Medical Centre 

12-14 Gloucester Street 
Brighton  BN 1 4EW 

Tuesday,  31  July 2018 

Mrs Veronica Hamilton-Deeley 
HM Coroner for Brighton and  Hove 
The Coroner's Office 
Woodvale 
Lewes Road 
Brighton  BN2 3QB 

Dear Mrs Hamilton-Deeley, 

We are writing  in  response to your Regulation 28 Report sent to the practice 
following the death of Mr DC. First of all,  I would  like to say how saddened 
everyone at the practice is by the death of Mr DC. He had been a patient of 
the practice for many years so many of us knew him well and  had tried to 
support him with his difficulties during his life. 

 and  I have been involved in 
Both the Practice Manager, 
investigating the matters of concern outlined  in your Regulation 28 Report, 
together with all the other doctors and administrative staff in the practice. 
Therefore, this report is being written jointly by 
also been read  and approved by my partners in the practice, 

 and me and it has 

. 

As is apparent from evidence available to the inquest and the investigation of 
the Police Liaison Officer,  Mr DC was able to obtain scripts for Zopiclone from 
the practice earlier than scheduled.  He did this by making electronic online 
requests which were processed by the practice and sent electronically to the 
pharmacist for dispensing. Despite looking into the computer system records, 
it remains uncertain whether electronic warnings about scripts being ordered 
too early were always triggered during this process. The settings on the 
computer, put in  place when the system was installed in  2013,  allowed scripts 
to go through within seven days of the due date without an alert or warning 
being triggered.  My recollection  is that Mr DC was on  a shortened repeat 
period,  i.e.  not 28 days but 7 or 14 days so a repeat script could have gone 
through without a warning/alert being generated.  Similarly,  patients were able 
to make an on line request for an  item on their repeat prescription list within  10 

 
 
 
 
 
 Actions taken so far taken in  response to Section 28 notice served by HM Coroner on North Laine 

Medical Centre: 

1.  A significant event analysis attended by the whole practice was held on 22 nd  May, 2018 to 
discuss the issues raised  by the case. An  action plan of 10 items was drawn up which has 
been read and signed by all participants in the prescribing/repeat prescribing process. 
2.  An  audit of all patients on Zopiclone was carried out to ensure that limits and doses were 
correctly entered on the system. There was no evidence that any other patients had over-

ordered or done so too early. 

3.  Access to online requests for controlled drugs has been removed for all patients. Following 

discussion with the patient and their doctor, this may be restored if the patient is considered 
"low-risk". 

4.  An  investigation into on line ordering and script generation by the computer system was 
conducted in conjunction with the practice IT co-ordinator. As a result, the timings were 
changed within the system so that warnings about scripts being ordered too early were 
changed from 7 to 1 day and ordering online from 10 to 3 days. 

5.  Patients who overdose will be added to the weekly script list. 
6.  There has been an extensive revision of the practice prescribing policy incorporating 

suggestions from the CCG  pharmaceutical adviser and we are having a practice meeting on 
24th  July to discuss further. We look forward to working with her again over the next year to 
improve further our systems. 

7.  There has been a raised awareness of the potential of any patient to over-order medication, 

whether by accident or design. 

8. 

 will continue to liaise with the CCG  and  other groups and will be a member of the T 
, 

and  F group looking into these issues. As part of this, he  had a meeting with 
the chair of the CCG,  on 23 rd  July where the issues involved were discussed and  he seemed 
supportive of the practice's efforts to address the problem. 
 has seen a draft of the 
report to be submitted by 
changes made by the practice. 

 and feels it accurately reflects the actions and 

9.  A whole practice meeting took place on 24th  July to discuss the updated practice prescribing 

policy . Ongoing review of patients on controlled drugs 

 will occur and a plan to reduce and/or stop agreed with the patient. This will 

complement what the practice already has put in  place over the past 2 years in terms of 
reduction programmes for patients. 

10.  A further meeting is planned with the practice IT coordinator to highlight automatically 

patients who have taken an overdose when certain high-risk drugs are requested. We hope 
to have this in place shortly. 

11.  We have self-referred as a practice to the GMC and are also liaising with NHS England  and 
the CQC.  We will be submitting a full report to NHS England at some point in the future. 

 Action plan following meeting held on 22 nd  May which have been implemented by the practice. 

1. All GPs are to be copied into reports of overdoses or other suicide attempts. This is the 
responsibility of the GP initially receiving the correspondence. 

2.  All overdoses or suicide attempts are to be coded into the system. We are looking to set up some 
kind of computer generated warning for patients who fall into this category but will need to liaise 
with the CCG/national computer system as to what information is appropriate/desirable to include 

3.  Receptionists and GPs are to be more aware of the possibility that patients may be ordering 
scripts too early, even if amounts appear "small". 

4. An  audit of all scripts for Zopiclone, was undertaken to ensure that the correct minimum number 
of days between script issues is entered on the repeat template. No evidence of any other patient 
ordering too early was found. Amounts of some prescriptions have been reduced . 

5. Any patients on the practice's weekly script system have been reviewed and their access to online 
prescription requests removed. The practice remains in control of the issuing of the script and 
ongoing reductions in certain medications is continuing. 

7. All patients on controlled drugs or drugs of potential abuse/dependence are being assessed  and 
their access to online requests for prescriptions removed. 

8.The receptionist processing repeat prescriptions for the day is to be given allocated and  protected 
time to process the scripts and the same will apply to the doctor signing them off. Receptionists 
have been reminded that the turnaround for prescriptions is two working days and  not to feel 
pressurised to take less time. 

9. We will discuss St Peter's Medical Centre's protocol for high risk medication and  how we might 
use this in the practice, particularly around medication reviews. 

10. Timings changed on computer system for warning about scripts being ordered too early to 
appear from 7 to 1 day before script due and ordering on line from 10 to 3 days. 

 North Laine Medical Centre 
Repeat Presc:ribing Policy 

1.  AIMS 

The purpose of this policy is to ensure that a simple and clear process for issuing 
repeat prescriptions is understood within the practice.  That clinical control is 
properly exercised, risks for patients are reduced and the most cost-effective 
medication is issued on time to meet patient need. 

2.  Management control 

All repeat medications are recoded on the practice GP System.  Controlled drugs 
are covered by the 'benzodiazepine prescribing policy'.  Medications issued on 
home visits will be recorded by the GP once he/she has returned to the practice. 

3.  Clinical Control 

The responsibility of the doctors is  as follows:  Doctors to make all 
additions/alterations to prescriptions: 

Medication should usuafly be prescribed generically,  unless contraindicated 
during the medication review/or advised by Hospital. 

To  be precise with directions e.g.  1 tablet twice daily,  rather than as directed, 
for clarity,  and so that over and under-use is apparent. 

To sign repeat prescriptions for patients at the end of surgery. 

Initiate repeat medications for new patients, review appropriateness (and cost) 
of medication. 
Following hospital appointment or discharge,  update treatment record and 
delete obsolete items. 

Medication linked to problems- All medications should be linked to a problem 
to be actioned by GPs opportunistically, when doing meds review when putting 
new meds on system 
Enter all drug allergies and adverse reactions codes onto the computer. 

PRACTICE  NURSE WILL ISSUE -
Dressings etc. 
Diabetic equipment 
Asthma equipment contraception 

RECEPTIONISTS WILL ISSUE  dressings, etc. requested by district nurses folic 
acid, ferrous sulphate, Peptac, and Mucaine requested by midwives and other 
items specifically authorised by GP for specific situations. 
Delete medication no longer used by the patient. See  below 
Duration of repeat prescriptions should usually be for 28/56 days. 

 The maximum duration will be 6 issues unless it is  a high-risk drug at discretion 
of Clinician.  Reception staff will no longer override the extra issue but will refer 
to the GP 

4.  Review dates: patients' medication to be reviewed at least annually, and 
code Medication review done entered onto clinical record.  Patients over 75 
years on 4 or more drugs should be reviewed every 6 months.  lf reception staff 
sees that a patient does not have a Review Date, please advise the GP. 

5.  High Risk Drugs 
Shared care Drugs 

Repeat requests for high risk drugs, e.g.  warfarin, lithium, DMARDs 
drugs are managed through the High-Risk Drugs protocol 
Some high risk drugs are identified as  part of the Les 84.  Every month a 
batch report listing the patient on high risk drugs is sent to the GP 
prescribing lead. Actions are then followed up with Lynn who 
coordinates high risk and substance misuse prescribing. This is a shared 
care service and our patients are monitored as  part of this specification. 
Uthium monitoring is performed via a recall system. 

file:///C:/Users/stempm/Downloads/safe_drug_mon_lcs_0ll_spec_vl.3%20(2 
).pdf 

Benzodiazepines, Z-Drugs and opiates/other controlled drugs 

Patients on this group of drugs must request repeat medications either 
via  Email, in writing or completing the side script. See  section 6, 
Reception staff. 

Patients who are on reducing regimes of medication or felt to be at risk 
of misusing medication will be placed on the list for weekly scripts. 
These will be processed by the nominated receptionist and are not 
available to be requested by the patient. They will be sent to the 
chemist in four weekly batches of a week at a time. Every four weeks, 
the medications are reviewed and reauthorized by the GP and 
reductions made, if appropriate. 

The practice is investigating the cost of dip testing new patients 
requesting high risk drugs or others already on  high risk drugs as part of 
their reviews. 
Additionally, patient included on the SMI  LCS  are managed in 
cooperation with the SMIL Nursing Liaison team. 

6.  Reception Staff. 

To  alert doctors if over or under-use of medication is  noticed, 
(usually written on px request) and  pass on  any request for new or changed 
medication to the doctor (usually as  a task). 

The Practice will not supply further repeat prescriptions at shorter time 
intervals than have been authorised (by GP)  without agreeing the reason for 
the early request, e.g.  holiday. 

2 

 Provided there appears to be  no problem, a prescription can  be generated and 
left for the doctor to authorise and sign. A list of situations where the GP must 
be advised are: 

1.  The clinical system indicates that a review is necessary 

2.  Any drug requested by the patient is not on their repeat record 

3.  Any of the following drugs may not be  requested  electronically. If on 

repeat then patient must email, complete the prescription side slip or 
request via their pharmacist. 

1.  Temazepam 
2.  Diazepam (Valium) 
3.  Dihydrocodeine 
4.  Zopidone and  Zolpidem and Tramadol oxycodone 
5.  Paracetamol and codeine 500/30 preparations, e.g. 

Solpadol, Zapain, oral morphine 

6.  All other controlled drugs 

4.  The item requested has been issued  less than one month previously 

5.  The overall date limit has passed 

6.  Any request about which the practice staff are concerned or uncertain. 

If the Review Date has passed, to print the side slip  'medication  review due' on 
the prescription and flag it to the doctor. On  EPS  a query note appears in the 
prescribing task list for the prescribing GP to action. The  overall date limit can 
be  extended by the receptionist for 1 month. Only on the express authority of 
the doctor.  The doctor decides whether the patient needs to come in for a 
review of their medication.  If not, the doctor updates the Review Date, and 
enters the code Medication review done.  If the patient's usual doctor is on 
leave, the repeat prescription is  issued as  normal, and the medication reviewed 
with the next prescription. 

Reception Staff are authorised to automatically delete all repeat medication 
older than 12 months except 
DO NOT stop seasonal/hay fever/Ventolin/ GTN sprays and Epipens and 
seasonal medication. 

Clinicians only will stop prescriptions older 6 months and they will be 

archived. 

To  make patients aware of the process for obtaining further repeat medications 
and encourage the use of the Online Patients Access.  To Also explain that the 
Review date is for the doctor to review the medication; they do not 
automatically need to see the doctor if it says overdue, unless there is  a 
Reminder message. 

7.  Patients' responsibility 

3 

 Should have a written record of their repeat medication. 
Repeat requests should be  made by ticking the re-order form, or in writing 
letter or fax,  on  line or via the nominated pharmacist. 
Patients should be prevented from over-ordering medicines. 
If they are unsure whether an  item should  be continued, they should discuss it 
·with a doctor. 
They should cross off items they no longer use. 
They should allow a minimum of 2 working days for prescriptions to be ready 
and  enclose a stamped addressed envelope if they want it posted. 
With the advent of EPS  all  patients should be encouraged to have a nominated 
pharmacy. 

8.  Prescribing Process 

Patients should give 2 working days' notice of a request for a repeat 
prescription. 3 working days'  notice is  required for medications that need 
reauthorising or are not on  'repeat'. Requests may be  made in writing and sent 
by post enclosing a SAE  left at the surgery reception or ordered via our on line 
patient Access.  Where a patient makes a request in  person then a repeat 
prescription request form should be completed. 

Repeat prescriptions may be posted to the patient, collected personally 
collected by some pharmacies the pharmacist. 
Telephone requests will not be accepted unless previously agreed. This policy 
avoids mistakes in  issuing wrong dosage or types of drug and  maintains the 
'Audit trail'. 

We will not telephone routine repeat prescriptions to a pharmacist in any 
circumstances. 

9.  For efficient use of Electronic Prescribing (EPS2):  Note we have now 

moved to electronic prescribing. The process we follow is: 

Ensure patient demographic data matches spine data 

Check that patient has a nominated pharmacy and that this information is up to 
date and correct, especially where patients have recently moved to the area. 

Ensure prescribed items are mapped to dm+d 

Ensure dosage instructions appear on the record  in  full,  not as  abbreviations 

Where a patient receives more than one repeat item, quantities, authorised 
issues/ review dates should be synchronized. 

Some medicines are currently excluded from EPS2  arrangements e.g. Schedule 
2 and 3 Controlled Drugs including temazepam and tram ado!. 

4 

 When registering patients, they should nominate a Pharmacy or if a Pharmacy 
arranges consent then the form is sent to the practice and scanned into notes. 

10. Administration and Signatures 

Reception staff will be  allocated protected time and should not be  interrupted 
by other staff member or answer patient queries unless the matter is urgent. 
All  repeats not received electronically should be prepared for signature at the 
end of morning surgery in protected time. All  EPS  requests are automatically 
assigned to Doctor. Then signed scripts will be: 

Posted to patient {include repeat prescription note) 
Place in  'to be collected' box on  main reception desk 
Retained Pharmacies boxes. Scripts are collected by Ross  and other local 
pharmacies in a secure bag normally daily. 
Faxed to chemist then posted {only for urgent requests usually via prior 
arrangement with chemist). 

Pharmacists will sign for all scripts collected at reception Check ID particularly 
when collecting controlled Drugs. 
Persons collecting controlled drugs on behalf of patients should provide a 
letter of authority from the patient; this can be in the form of an email.  Once 
authority received make a reminder. 

All  medication issued must be  recorded on GP system. Please  record 
destination of script /e.g. SAE,  Ross. 
Basic Training is provided in house additionally we did receive one day's 
formal training from the CCG  when we moved to EPS. 

11. Acute Re-Authorisation Requests 

Those requests that cannot be authorised by the prescribing team are tasked to 
the Duty GP task box to be  reviewed and  issued accordingly. 
Any on the day urgent requests are flagged green and the appropriate clinician 
is advised these are waiting. 

12. LOST PRESCRIPTIONS. 

If a prescription is  reported as lost, check the date of issue and  any places 
where it could possibly be - i.e. misfiled, sent to the chemist or an  incorrect 
chemist. 
lfthe prescription cannot be found reprint the prescription - do not re-issue 

Make an  entry in the patient's notes (quick note) why re-issued the date of the 
prescription and that it has been re-printed. 
Write note in book for lost prescription. 

Patients who report that their medication or prescription has been stolen 
should report the matter to the police and obtain a crime number. 

5 

 Patients who regularly "lose" their prescriptions should be seen  by a GP  who 
will decide if it is  appropriate to re-issue the prescription. 
Under no circumstances must a receptionist re-print or re-issue a prescription 
for controlled drugs, this must be actioned by the Duty GP/Pharmacist. 

13. Uncollected Prescriptions-

The Prescription basket should be checked thoroughly on the first week of 
every month for uncollected prescriptions. This needs to be done to highlight 
any potential safeguarding issues or problems to the GP.  (Old  Rxs  ie 2 months 
or over should be passed on to GPs before destroying as GPs should be made 
aware if patients aren't taking medications. (Record destroyed Rxs  in  PMR) 
Mark prescriptions in error, right dick on the medication screen and give a 
reason of not collected by patient. 

These are coder 'Prescription not collecte:d1  Read  code browser on S1 

14, Medication reviews. 

The  Practice supports the principles of the medication review described in the 
briefing paper www.medicines-partnership.org/medication-review 
http://www.npc.eo.uk/med  partnership/assets/room  for  review.pdf 

We undertake a full medication review with patients usually face to face and 
occasionally using the patient's full notes. We adopt the following principles: 

1.  Al!  patients have the chance to raise questions and 

highlight problems about their medicines 

2.  Medication review seeks to improve or optimise impact of treatment 

for an  individual patient 

3.  The review is  undertaken in  a systematic way by a competent person. At 
this practice, this is always the Doctor. Reviews are triggered annually 
for al!  patients on the chronic disease registers. Additionally, patients on 
regular repeat medication will be  invited in for a review at intervals 
defined by the Doctor.  Normally 6 months the reviews will be  at 6 
months unless indicated otherwise. 

4.  Any changes resulting from the review are agreed  with the patient 
5.  The review is documented in the patient's notes. 
6.  The impact of any change  is monitored. 

MAS Prepared February 2007 
MAS/RMcP/MJAS Reviewed July 2018 

6