David Travers

Medicines Optimisation Team 
NHS Northern, Eastern and Western Devon  
Clinical Commissioning Group 
Windsor House, Tavistock Road 
Plymouth PL6 5UF 
Telephone: 01752 398800 

Email: D-CCG.medicinesoptimisation@nhs.net 

 16 August 2018 

Her Majesty’s Coroner for the County of Devon 
Plymouth, Devon and Torbay Area 
HM Coroner’s Court 
1 Derriford Park 
Derriford Business Park 
Plymouth PL6 5QZ 
Stephen Covell, Assistant Coroner 

Dear Mr Covell, 

Re: Regulation 28 report to prevent further deaths  

Ref: SC/SF/2736-17, 21 June 2018 

This is the official joint response of the Devon Local Medical Committee (Devon 
LMC) and NHS Northern, Eastern and Western Devon Clinical Commissioning 
Group (NEW Devon CCG) to the concerns you raised following the inquest of David 
Lee Gomer Travers on 24 May 2018. 

Our joint response is divided into two sections: 

1.  Actions already completed 
2.  Proposed actions agreed at a meeting held on 07 August 2018 

1.  Actions already completed 

a.  Full consideration of the individual elements of this Drug Related Death (DRD) 

by study of the Root Cause Analysis and associated paperwork. Our first action 
was to gather as much information as possible to understand the full background 
to the DRD and the information shared at the inquest. The documents reviewed 
included the following: 

  Livewell SW Serious Incident report (SIRI) and Appendix A ref: 2017/26811 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   Livewell SW Root Cause Analysis (RCA) incident ref. no.: 82917  
  Livewell SW letter to Safety Systems Team, NEW Devon CCG dated 09 

February 2018 

  Quality Review Template of a RCA Investigation Report, South Devon and 

Torbay (SDT) CCG / NEW Devon CCG 

  Plymouth Herald report 24/5/18 of the inquest of David Lee Gomer Travers 
  NHS Audit South West Patient Alert re: David Travers issued 23rd June 2017 
  Primary Medical Care Services Special Allocation Scheme (SAS) 2018 

policy and guidance (replaces former Violent Patient Scheme) 

b.  Agreement between Devon LMC and NEW Devon CCG to work together on a 

joint response to the regulation 28 report. 

c.  System wide meeting planned. It became clear from the outset that the concerns 
you raised were multi-faceted and that we would need the input of many different 
organisations to fully inform the process. We therefore convened a meeting of 
representatives from the following organisations or teams which took place on 7th 
August 2018: 

  Medicines Optimisation Team (MOT), NEW Devon CCG 
  Devon LMC Chair 
  Local NHS Counter Fraud Specialists, 
  Controlled Drug Accountable Officer (CDAO), NHS England South, South 

West 

  Public Health Specialist, Plymouth City Council 
  Practice Manager, Peverell Park Surgery, Plymouth 
  Clinical Risk Adviser, Livewell SW 
  Clinical Director of Pharmacy, University Hospitals Plymouth (UHP) / 

Livewell SW 

  Community Forensic Team Manager, Livewell SW 
  Drugs Liaison Officer (DLO), Devon and Cornwall Police 
  General Practitioner, NEW Devon CCG / Ernesettle Practice, Plymouth 
 

Information was also received from the Safety Systems Team, NEW Devon 
CCG (though they were unable to attend the meeting).  

  Those attending this meeting were given advanced notice to consider 

potential solutions to the concerns you raised, namely: 

‘Evidence from several witnesses indicated that Mr Travers was able to access 
multiple prescriptions for drugs by moving around Plymouth and the surrounding 
area and presenting to different GP surgeries as requiring drugs. 

Evidence also indicated that Mr Travers would sell or barter prescription drugs to 
obtain illicit drugs. 

There are apparently measures in place to raise alerts across GP surgeries and 
NHS Trusts to exchange information about persons who may be attempting to 
exploit the issuing of drug prescriptions, however given the above evidence, I am 
concerned that it nevertheless still too easy for persons to access multiple 
prescriptions. This presents a risk to those who are able to obtain and take 
excessive amounts of prescriptions drugs and a route by which prescription 

 
 
 
 drugs can enter an illegal drugs market.’ (Taken from Coroner’s report dated 
21/06/18.) 

d.  Reflection by NEW Devon CCG MOT on the patient alert paperwork and system, 

including the usefulness, appropriateness of information for sharing, 
effectiveness and ease of use, resulting in the following action:  

Action: concerns taken to the system wide meeting held on 07/08/18. 

e.  Understanding the current SAS system for violent patients and if this could have 

helped Mr Travers.  

There are two problems associated with this: firstly the new system has only 
been introduced this year, the former system was more difficult to instigate and 
not widely used within primary care; and secondly the system does depend on 
patient engagement. The RCA found that Mr Travers did not engage well with 
any of the services he was offered. We did take the discussion on SAS to the 
system wide meeting however; as we thought it may be part of the solution in 
curtailing multiple GP registrations for a small number of patients.  

f.  The letter from Livewell to Safer Systems included two points, the first related 

directly to the concerns you have raised; however, the second point highlighted 
the lack of information provided by the Prison discharging Mr Travers in March 
2017. There has been a further DRD this year in which a lack of salient 
information from the prison on discharge was implicated as a potential 
contributing factor. NEW Devon CCG is in negotiation with the prison provider 
Care UK, to improve the provision of health information to primary care for 
people released from prison. This will preferably be by electronic means as the 
prison service uses the same computer software as the majority of GP practices 
in Devon. This action has been added to the action tracker (see section 2) to 
ensure it is completed.                            

g.  Acknowledgement that the Adastra system is available for alerting out of hours 
services of patients who are likely to seek drugs of divergence and for out of 
hours providers to record supplies in the patient’s care record, although this 
process could be made easier to use. 

h.  NEW Devon CCG has a current work stream “Pain and distress management 

system optimisation group” where the need to provide support to GPs and other 
prescribers for patients with drug seeking behaviours has already been 
recognised.  

2.  Proposed actions agreed at the system wide meeting held on 07 August 

2018 

A wide range of views were shared at this meeting and it was agreed that there 
are a set of actions that can be carried out at a local level but that some of the 
problems can only be solved at a national level. It was recognised that any 
system will always have weaknesses that can be exploited by a criminal mind. 
Equally we recognise that a balance needs to be struck between absolute 
control of issue of prescriptions and the need to provide ease of access to 
prescribed medicines for the vast majority of genuine patients. We have 

 
 
 
 
 
 
 
 therefore made some recommendations which we think should help to improve 
control without reducing ease of access, but will need to be agreed. 

a.  Recommendations for action at a national level 

i.  NHS Digital is responsible for the NHS spine IT systems. Most of the 

recommendations in this section will need to be directed to NHS Digital for 
evaluation of feasibility. 

ii.  Mr Travers was dual registered at two Plymouth GP practices during April, May 
and June 2017. This meant he had two sources for his prescriptions within a 
short distance of each other. It was stated at our meeting that although dual 
registration should not happen, the NHS spine is so slow to update records that 
this is possible. A patient requesting registration at a GP practice who has 
recently registered elsewhere will not necessarily show as already registered, 
the system can take six weeks or longer for registration details to update. This 
is clearly unacceptable and allows patients to potentially manipulate the system 
if they are so inclined. 

We recommend that registration details are immediately uploaded to the 
NHS spine so that attempts to register elsewhere will not be possible. 

iii.  Patients away from home who need medical care or prescription supplies can 
be prescribed up to 14 days’ medicines as an emergency supply (ES) or can 
register with a practice as a temporary resident (TR) if they are in the area for 
longer than 24 hours but less than 3 months. Mr Travers managed to obtain 
medication from four different Cornish practices within a week in June 2017 
either as ES or TR supplies. ES can be made without proof of identity or to 
patients without a fixed abode. Homeless patients are entitled to register with a 
GP using a temporary address which may be a friend's address or a day 
centre. The practice may also use the practice address to register them. We 
are therefore planning to issue local guidance about checks to be made if there 
is a degree of suspicion about these requests (see section 2) b)). TR 
registrations do not appear on the NHS spine so each practice approached in 
this way will not know if the patient has abused this privilege.  

We recommend that TR registrations are immediately uploaded to the 
NHS spine to prevent multiple registrations.                                            

iv.  We discussed at length the patient alert system and its deficiencies (see part 2) 

b) for local actions) and also the Special Allocation Scheme (SAS) for violent 
patients.  

We recommend that any patient alert or SAS registration should 
automatically be linked to the patient’s record on the NHS spine so that 
all healthcare professionals (HCPs) are aware of this during 
consultations. 

v.  The patient’s basic details are held on the NHS spine as a Summary Care 
Record (SCR) which can then be viewed by all HCPs authorised to do so. 
Patients can opt out of their details being shared on an SCR but 98% practices 

 
 
 
 
 
 
 
 
 are now using the system. The SCR currently includes a list of the patient’s 
regular medicines and a date of last issue. However this only relates to issues 
from the patient’s registered practice.  

We recommend that the SCR should include details of all medication 
issued within an agreed time frame including any supplies issued as a TR 
or as an ES (if the patient’s details can be accessed via the spine). 

vi.  Patients seeking additional supplies of prescribed medicines often use aliases 
and alternative addresses or dates of birth thus making them difficult to identify 
on the NHS spine.  

We recommend patients known to be using aliases should have this 
information included on the SCR. We also recommend the use of a mobile 
phone number as an additional identifier as many patients using aliases 
still use a consistent mobile number. 

Additionally we recommend that any attempts at dual registration and 
requests for ES or TR for known patients are automatically flagged to the 
patient’s registered practice to improve communication about fraudulent 
activity. 

Ensuring that all clinical systems are compatible with each other to allow 
sharing of files and information would greatly assist the process of 
reducing inappropriate prescribing. 

b.  Local actions planned for NEW Devon CCG supported by the LMC and 

local system partners including those represented at the meeting. These 
are described below and have been included within an action tracker 
including owner details and target completion dates. 

i.  Review of the Patient Alert Scheme. We recognise that the current scheme 

has some deficiencies so we recommend the following changes: 

 The scheme is managed by NHS England and NHS Audit South West so we 

recommend these two agencies work together to agree improvements. 

 These are actions that can be completed locally prior to any of the 

recommended improvements to the NHS IT systems being implemented. 
 The current alert notification includes a considerable amount of information 

some of which may be highly confidential. This results in the need to make a 
judgement of who to send it to on the basis of need to know and compliance 
with data protection regulations.  

We propose that the only information necessary is name (and any 
aliases), NHS number (if known), Date of Birth and registered practice (if 
known) with a very brief description of the concern e.g. “attempting to 
obtain additional medication” or “has been violent / threatening to staff”. 

We propose to investigate the feasibility of compiling a list of patients on 
the alert scheme along the lines of the SAS scheme with the need for 
each patient to remain on the list reviewed after 3 months. Each time a 

 
 
 
 
 
 
 
 
 
 new patient is added or one is removed would result in an updated list 
being sent electronically to all sites. 

The alert list would be sent to all GP practices, hospital emergency 
departments / admission units, community pharmacies, minor injury 
units, walk in centres, private hospitals and dental practices. 

 On receipt of the alert list all the above sites should ensure that the names are 
uploaded to the clinical system and easily accessible to authorised staff (this 
will form part of the guidance to practices, see below). 

 If an individual on the list is identified, their registered practice (or other 

identified contact) must be informed and no medication should be issued. 

ii.  The Special Allocation Scheme (SAS) 

 The new national scheme is to be communicated and promoted to all GP 

practices in NEW Devon. A police log number is an essential component of the 
scheme. 

 We propose that an up to date list of patients on the scheme is provided to all 

practices and that the patient record is annotated with VP. 

 Practices will need to have a system to manage the list. 

iii.  Guidance on dealing with drug seeking behaviour to be produced and 

disseminated to GP practices and others (some elements of this will also be 
applicable to hospitals, community pharmacies, MIUs, walk in centres and 
dental practices. These sites should be encouraged to adopt relevant parts of 
the guidance). The guidance should cover the following broad themes: 

 Profiles of drug seeking individuals with common themes and techniques used. 

Newly registered patients seeking drugs of divergence should be checked 
against the patient alert and SAS scheme lists. 

 Understanding the range of medication subject to abuse / diversion and the 
street values of drugs (as provided by the police). Emphasise the current 
excessive use of pregabalin and its leakage on to the black market. 
 Strategies for resisting excess prescription requests and the support 

mechanisms available for prescribers. 

 Ensuring there is a practice system for recording and flagging patients over-

ordering, subject to patient alerts or SAS patients. Lack of NHS spine record or 
patients without a fixed abode should raise concerns (however note there is an 
obligation under GMS to register homeless patients). 

 Advice on the process for flagging individuals with drug seeking behaviours to 

other GPs and out-of-hours providers. 

 Always report lost prescriptions / drugs of dependence to the police and record 

the police log number. 

 All prescribers within a practice (including locums) required to sign they have 

read the guidance.  

 Peer review of prescribing rates for drugs of dependence 

iv.  The above guidance to be supplemented by specific protocols held by the LMC 

from practices which have good systems in place to be available for practices 
on request if they would like to employ tried and tested systems rather than 
designing their own. 

 
 
 
 
 
 v.  Education and training to include the themes in iii) above. This to be provided at 

confederation meetings, to final year medical / dental / non-medical prescriber 
students, registrars and newly qualified GPs.  

vi.  Devon & Cornwall Police DLO to provide training on how to identify drug 

seeking behaviour and share stories from undercover work which has caused 
professionals to reflect on their prescribing. There was agreement that this 
would be best delivered face to face via GP forums, or by creating a video for 
sharing 

vii.  Agreement that UHP will take action to ensure that the details of the medicines 
that a patient is discharged with is more clearly noted on the discharge 
summary. 

We will communicate our recommendations for national action through NHS England 
and would value your support in promoting them nationally also. 

An attendee at the meeting from Livewell Southwest, who was involved in the 
inquest, highlighted the positivity of holding the meeting and the importance of 
sharing the recommendations and plans with the family of the deceased. We kindly 
ask that you consider this as you find appropriate. 

We trust this response satisfies the requirements of your regulation 28 report. 

Yours faithfully, 

Head of Medicines Optimisation 
South & West Devon,                    
NEW Devon and SDT CCGs 

Chair – Devon LMC