Ruth Edwards

Q G IG Bwrdd lechyd Prifysgol Ysbyty Athrofaol Cymru
Tpapt

Caerdydd a'r Fro University Hospital of Wales
ojo i! “ . a -_ UHB Headquarters
N H S Cardiff and Vale Heath Park Pare Y Mynydd Bychan
£ & | University Health Board — Cardiff, CFl4 4xw Caerdydd, CF14 4X

Len Richards
Chief Executive

12 February 2019

Miss R Knight

Assistant Coroner

Coroner's office

The Old Courthouse

Courthouse Street

Pontypridd

CF37 1JW

Dear Miss Knight
Ruth Ellen Edwards (deceased) D.O.D. 31/08/2018

Thank you for your letter of 20 December 2018, in which you outline your concems
regarding the death of Mrs Ruth Edwards, and issue a Regulation 28 order detailing
the areas you wish the University Health Board to consider.

We recognise that this will have been a very difficult time for Mrs Edwards's family
and would like to offer our most sincere condolences. The University Health Board
has conducted an internal review of the processes (known as the Multi-Disciplinary
Case Review or MCR) involved in the care and treatment offered to Mrs Edwards
following her presentation at the University Hospital of Wales (Accident and
Emergency). Unfortunately no member of UHB staff who were involved in dealing
with Mrs Edwards were called to give evidence at the Inquest and it may have been
possible to provide some further assurance in relation to the areas of concern that
have been highlighted.

Your concerns with regards to her care are as follows:

That Mrs Edwards was discharged from hospital following an overdose on 234
August to see GP was surprising. It was expected in these circumstances that
Mrs Edwards would have been transferred to Llandough Hospital for a
psychiatric liaison assessment instead; responsibility for any further
assessment and treatment of Mrs Edwards was passed entirely to Mrs
Edwards and her family.

A less capable family/individual may not have pursued help and fallen through
the cracks. Furthermore had Mrs Edwards been hospitalised, her treatment
may have been different.

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The findings of our internal MCR concluded that the care and treatment given to Mrs
Edwards fram the point of the mental health assessment conducted by the REACT
team the following day, was comprehensive and demonstrated full awareness of Mrs
Edwards's history, her level of risk, the true nature of her overdose the previous day
and balanced this against the capability of Mrs Edwards's family to provide a safe
and supportive context.

The UHB would absolutely concur that some families may not have been in a
position to provide ongoing support, but the judgement that Mrs Edwards might
remain at home with regular and frequent input from the REACT team was made
with the conscious participation and agreement of all, including the team, the patient
and the family.

It is clear from the accounts given by all professionals involved that consideration
was given almost on a daily basis to whether Mrs Edwards should be admitted to a
hospital bed. It is equally clear that this was consciously balanced against the
possibility that hospital admission may have been detrimental to Mrs Edwards. Mrs
Edwards herself was not amenable to hospital admission. It is normal and good
practice to provide treatment and support at home wherever possible, and it was
concluded that the decision to do this was appropriate in this case, based on the
information that was available to clinicians at the time.

The consultation at the UHW on 23 August was poor. The history taking was
inadequate as it did not reveal the true extent of Nrs Edwards risk in terms of
previous suicide attempts and deep seated mental health problems.
Furthermore, inaccurate information was communicated to liaison psychiatry;
they were told that Mrs Edwards had taken 2 tablets when she had taken 20.

Mrs Edwards had not had any involvement with mental health services for many
years, and there was therefore no information available to the assessing doctor from
either paper notes or the electronic PARIS mental health record system.

would therefore have been restricted to the information that Mrs Edwards (and those
accompanying her) gave him at the time. Had Mrs Edwards's involvement with
mental health been within the last several years, then a PARIS history would have
been available to and will be available for other patients presenting in
similar circumstances.

Our review has identified that, although there was 4 typographical error in the
documentation stating that only two tablets of Sertraline had been taken when in fact
the true figure was twenty, this error was rectified on the night In question: when
HB bad his discussion with Mark Bates (the night site coordinator for mental
health services), both individuals knew that twenty tablets had been taken and made
their clinical decision on that basis. This is borne out by the notes taken by

at the time, and also | can confirm that the night site coordinator in mental health
services has located his own personal notes from that night, in which he has written
that Mrs Edwards took twenty tablets, not two. The typographical error was therefore
not a factor in the decision making process on that night.

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The GP practice may not have performed suitable frequent medication reviews
with Mrs Edwards. Many boxes of different tablets were found at the family
home. Many on repeat prescription posing an overdose risk.

This issue will be raised this with the Primary, Community and Intermediate Care
Clinical Board as a practice issue for them to consider.

With regards to the specific issues you have asked the UHB to consider in
order to prevent future deaths:

The identification of patients who require Immediate psychiatric assessments
and review by specialist teams.

The UHB uses the Bristol Matrix, a decision making tool which is used to support the
identification of patients who require psychiatric assessments. This decision making
can also be conducted jointly with senior mental health staff. | can confirm that
training in the use of the Bristol Matrix is well established, that all junior doctors learn
about it during their induction to the department and are familiar with its use which is
standard practice in this kind of situation.

The doctor that conducted the initial assessment is a locum in the department but
has many years' experience in emergency medicine and works regularly in the
department. She has had training in the assessment of the patient with mental health
problems and would have felt confident in entrusting a decision that the patient was
low risk and safe for out- patient review.

The care and attention to detail taken by doctors and other healthcare
professionals when nothing histories and information from mental health
patients.

Although the internal MCR has identified a typographical error as described above
the general standard of documentation was found to be satisfactory. All staff will,
however, be reminded of the importance of full and diligent information taking, using
all information that is available at the time and this will be achieved through the
Clinical Board’s Quality, Safety and Experience structures.

The frequency of medication reviews with mental health patients

Mrs Edwards was not known to secondary care mental health services at the time of
her death. Her care was being provided by her General Practitioner. The
management of patients with Depression is carried out in line with NICE Guidance
‘CG90 — Depression in adults: recognition and management’ and there is a standard
for the regular review of patients depending on the nature and severity of their
depression. This matter has been raised with the Primary Community and
Intermediate Care Clinical Board as a practice issue for them to consider.

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| hope that the information set out in this letter provides you with the assurance that
the Heaith Board has fully considered the issues raised as a consequence of the
inquest into Mrs Edwards’s death, and has taken appropriate action in response.

Yours sincerely

Len Richards
Chief Executive

Haws

WEST QUAY

MEDICAL CENTRE

of January a) Hood Road, Barry
Vale of Glamorgan, CF62 SQN
Our ref: RL/j T: 01446 722 792

F: 01446 733 555

www.westquaymedicalcentre.co.uk.

Your ref: 14926

Coroner's Office
The Old Courthouse
Courthouse Street
Pontypridd
Rhondda Cynon Taf
CF37 1JW

Dear Assistant Coroner

Re: Mrs Ruth Edwards DOB. 29/01/1953
52 Celtic Way
Rhoose
Barry
CF62 3FT

Many thanks for the report and investigation into the circumstances
surrounding the sad death of Mrs Edwards. | have read the comments on the
report and would entirely agree with those that have been painted out.

Specifically with relation to the comments regarding medication reviews with
ourselves as General Practitioners, we would recognise that this presents a
particular challenge to us and safe prescribing of medicine requires a great
deal of resource. In the last 12 months we have taken on a Clinical
Pharmacist within the Practice Team on a full time basis whose responsibility
it has been to oversee and improve the governance regarding repeat
prescribing and acute prescribing of medications plus patient monitoring. We
have in fact achieved an NHS award for quality improvement in this area and
although this may have come too late for Mrs Edwards in order to reduce her
risk, ! would be confident that we have made great strides over and above that
we would expect to meet standards of our General Practice.

That said, we would also bring these comments to our monthly significant
events meeting to highlight the importance of medication reviews and high risk
patients. to all of our clinical staff.

| hope this in someway can reassure the family that measures are being made
and that Mrs Edwards will at least go someway to improving medication safety
for other patients in the future.

Yours sincerely