Graham Saffery

24 December 2019
Our ref: 2303

Emma Whitting

HM Senior Coroner
Bedfordshire and Luton
HM Coroners Office
Woburn Street

The Court House

NHS}

Bedfordshire
Clinical Commissioning Group

Corporate Office

Suite 3, Capability House
Silsoe

Bedford

MK45 4HR

Tel: 01525 624275

Email: bccg.complaintsandfoi@nhs.net

Ampthill Website: www.bedfordshireccg.nhs.uk
Bedfordshire ‘

MK45 2HX

Dear Ms Whitting

Inquest into the death of Graham Saffery

Thank you for your letter dated 17 September 2019, detailing your concerns following
completion of the Inquest into the death of Graham Saffery.

Firstly, on behalf of Bedfordshire Clinical Commissioning Group (CCG), | would like to pass
on my condolences to Graham Saffery’s family for their tragic loss, such a difficult time for
family and friends.

Please accept my apologies for the delay in responding. Our Head of Medicines
Optimisation, Primary Care team and Quality and Safety team have been involved in the
investigation and | understand in depth discussions have taken place with Queen Parks
surgery and Further questions arose from the investigations which required
additional information to be obtained causing delay. Our investigation has now concluded
and | am in a position to formally respond.

We would like to address the following two points raised in your letter:

1. Although at the Inquest |-heard from] from Queens Park Health Centre, |
did not hear from]§§§f/iEEwho had last attended on Graham on 14% June 2018
and as a result | made no particular finding about Graham’s presentation on that
occasion; however, | was concerned that, at least from a reading of the patient
records EEE did not appear to have observed that, since 23 May 2018,
Graham had been receiving double his prescribed dose of Amitriptyline, apparently
without explanation.

CCG response: has submitted a detailed report to the CCG for consideration
alongside the practice report. During the consultation (14'" June) EEEEEnoted the dose

of the amitriptyline to be 75mg daily. The dose of amitriptyline had been recommended to
be doubled a = East London NHS Foundation Trust (ELFT), our community
mental health provider, which we have confirmed verbally with ELFT, but no communication

NHS)

Bedfordshire

Clinical Commissioning Group
had been received by Queens Park to this effect. The practice have never prescribed
amitriptyline 150mg daily, however it is possible Mr Saffery may have been taking this
dose on the recommendation of the Mental health specialist, following the telephone
consultation. This is the maximum licensed dose for amitriptyline for depression as per the
specific product characteristics and therefore is within guidelines.

2. was also concerned to learn, through evidence provided by Bedford Hospital prior to
delivering my Summing Up and Conclusion, that although the hospital discharge
letter (in respect of Graham's admission 27-29 May 2018) had been downloaded by
the Queens Park Health Centre at 15:14 hrs on 31 May 2018 i informed
the inquest that he had not been made aware of it and that the letter had not been
incorporated into Graham's patient records.

CCG response: The hospital discharge summary had been received by the practice
through the electronic GP portal information system and rather than going into the ‘letters’
inbox at the practice it had gone into the ‘reports’ inbox and therefore had not yet been
actioned as letters are processed with a higher priority. This was an administrative error
which has now been addressed with the hospital.

Members of the Primary Care team and Medicines Optimisation team have met with
Queens Park surgery and the practice have reflected on the tragic death of Mr Saffery and
made changes to their prescribing protocols and management of controlled drugs, in
particular how they manage patients on weekly prescriptions.

The Head of Medicines Optimisation at the CCG has shared the detailed report from
Queen's Park Surgery wit EEE Controlled Drugs Accountable Officer for the
East of England (NHS England) to ensure that the learning is shared across the region.

As learning from this incident, Bedfordshire CCG has taken the following actions to help
identify any future patients at risk:

e The case has been discussed at the Prescribing Committee and it was agreed that’
the learning should be shared across all practices.

e The CCGs Locality team have developed and published a SystmOne search to
identify any patient, in the GP practices, on a high strength opioid and a tricyclic
antidepressant.

e All prescribing leads have been briefed on this case at the prescribing leads
meetings and asked to run the search and ensure all patients are reviewed and the
review is clearly documented in the notes, with the necessary care plan as
appropriate.

e The NHS National Business Services Authority have published a dashboard to
include patient numbers on a combination of oxycodone and amitriptyline and the
CCG team will continue to monitor numbers to ensure reviews have taken place.

e The Head of Medicines Optimisation has met with the chief pharmacists at both the
Luton and Dunstable Hospital and Bedford Hospital and also the Chief pharmacist at
ELFT to discuss the learning from the case.

NHS

Bedfordshire
Clinical Commissioning Group
We are not expecting that all patients identified on a combination of an opioid and tricyclic
antidepressant will have their medication stopped, but the risk associated with the level of
sedation will be reviewed and action can then be taken as appropriate. The use of low
dose opioids with low dose amitriptyline may be clinically appropriate.

| hope that | have been able to answer your questions. If! can be of further help, please
get in touch.

Yours sincerely

Accountable Officer