Wendy Wilkes

Greater Manchester Health and Social Care Partnership 
4th Floor 
3 Piccadilly Place 
London Road 
Manchester M1 3BN 

T: 07825 675 823 

E: 

Your Ref: Case 313457 

04 June 2020 

Ms A Mutch OBE 
HM Senior Coroner 
Coroner’s Court 
1 Mount Tabor Street 
Stockport 
SK1 3AG   

By email: coroners.office@stockport.gov.uk   

Dear Ms Mutch  

Re: Regulation 28 Report to Prevent Future Deaths – Wendy Margaret Wilkes 
06/08/19    

Thank you for your Regulation 28 Report dated 21 April 2020 concerning the death 
of Wendy Margaret Wilkes on 06 August 2019. I am sending this reply by email to 
the above address as discussed and agreed by my PA 
 and your 
office today.   

Firstly, I would like to express my deep condolences to Wendy Margaret Wilkes’ 
family.  

The inquest concluded that Wendy Margaret Wilkes’ death was a result of 1a) 
ethanol toxicity on a background of concomitant use of gabapentin, zopiclone, 
diazepman and amitryptiline; II) Alcohol related fatty liver disease.  

Following the inquest you raised concerns in your Regulation 28 Report to NHS  
England regarding that there was no clear system of alert notes/follow up review 
appointments at her GP practice despite the extent of the prescribed medication; 
The GP practice did not appear to have a system to ensure that prescribers were 
aware that her alcohol use was high and to assess the risk of mixing alcohol with the 
prescribed medication. 

 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 I have noted that your Regulation 28 letter has also been sent to the Clinical 
Commissioning Group concerned and I will leave it to the named respondent to 
address the concerns which you have expressed. My letter therefore addresses the 
issues that fall within the remit of GMHSCP. 

Summary of actions taken or being taken by the organisation involved. 

The CCG will ensure that; 

1.  Practices will undertake a search on a quarterly basis for patients coded as 

taking opioids or neuropathic drugs cross referenced with alcohol dependency 
so that they can understand their existing cohort of at risk patients, place a 
flag on their record, review their medication and contact them to discuss their 
medication and their consumption of alcohol. 

2.  When a practice becomes aware of any patient who has overdosed, whether 
accidentally or intentionally, a flag should be placed on their records, their 
medication will be reviewed and a discussion be had with the patient about 
their medication and their alcohol consumption. Place the patient on weekly 
prescriptions to reduce the possibility of any further harm if it is deemed 
clinically appropriate after a discussion with the patient.  

Actions taken or being taken to prevent reoccurrence across Greater 
Manchester.  

1.  Learning to be presented/shared with the Greater Manchester Quality Board.  

This meeting is attended by commissioners, including commissioners of 
specialist services, regulators, Healthwatch and NICE. 

2.  Learning to be shared with the Greater Manchester commissioners of 

services to assure themselves of the quality of services they commission. 

3.  An alert will be issued to all GP practices to ensure that they have clear 
systems of alert notes/follow up review appointments for individuals with 
extensive prescribed medications. The alert also requests GP practices 
consider how their systems can alert prescribers to patients with high alcohol 
usage when prescribing medications to ensure effective risk assessments can 
be carried out. 

Previously, across Greater Manchester, a set of nine standards were developed to 
improve quality and reduce unwarranted variation in the delivery of primary care. The 
standards were first developed in 2014 and a refreshed version implemented in 
2018.  

The system remains committed to ensuring that Standard 7 – embedding a culture of 
safety – which aims to make Greater Manchester the safest, most effective place to 
receive medicines and treatments is achieved. It aims to improve reporting rates of 
medicine related safety incidents, improve uptake of safety audit software and 
reduce medicine safety incidents over time. Specifically, this includes establishing 

 
 
 
 
 
 
 
 
 
 
 
 
 
 processes of shared learning / peer reviews within a practice and neighbourhood 
setting, including incident reporting, lessons learnt, embedding remedial actions and 
review processes. All 10 localities implemented this standard in full or in part and are 
committed to improving medication safety. Local examples of this include locally 
commissioned quality improvement programmes, closer working with CCG 
medicines management teams, inclusion of safety champions and medicines 
management peer reviews.  

The Greater Manchester Health and Social Care Partnership (GMHSCP) is 
committed to improving outcomes for the population of Greater Manchester. In 
conclusion key learning points and recommendations will be monitored to ensure 
they are embedded within practice. 

I hope this response provides the relevant assurances you require. Thank you for 
bringing these important patient safety issues to my attention and please do not 
hesitate to contact me should you need any further information. 

Yours sincerely 

Dr Richard Preece 
Executive Lead for Quality and Medical Director

Strictly Private and Confidential 

Alison Mutch OBE 
HM Senior Coroner 
Coroner’s Court 
1 Mount Tabor Street 
Stockport  
SK1 3AG 

Dear Ms Mutch 

CHIEF EXECUTIVE 

Steven Pleasant MBE 
Chief Executive, Tameside MBC 
and Accountable Officer, Tameside & Glossop CCG 
Tameside One, Market Place, Ashton under Lyne, 
OL6 6BH 

www.tameside.gov.uk 
e-mail :      
Call Centre            0161 342 8355 

Case: 313457 
let/sp1165 

Your Ref 
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Date                      15 June 2020 

Wendy Margaret Wilkes - Regulation 28 Report to Prevent Future Deaths 

Further  to  your  letter,  dated  20  April  2020,  regarding  the  tragic  case  of Wendy  Margaret  Wilkes 
please find my response outlined below. 

The untimely death of a person is distressing for their family and any others affected by their death 
and  loss,  and  all  the  more  so  if  there  is  any  belief  that  but  for  the  actions  of  any  organisation  it 
could have been avoided.    

I would like to record my sincere condolences to the family of Wendy Margaret Wilkes for their loss 
and I hope through this process they can obtain some closure. 

Your  report  highlights  concerns  raised  with  the  Regulation  28  Report  to  Prevent  Future  Deaths 
were as follows; 

 

 

No clear system of alert notes/follow up review appointments at her GP practice despite the 
extent of the prescribed medication; and 

The General Practitioners’ Practice (“Practice”) did not appear to have a system to ensure 
that prescribers were aware that her alcohol use was high and to assess the risk of mixing 
alcohol with the prescribed medication. 

The  Haughton  Thornley  Medical  Centres  have  undertaken  a  Significant  Event  Analysis  of  the 
circumstances, which was subject to a Clinical Peer Group discussion of all General Practitioners 
Haughton Thornley Medical Centres at a GP meeting on 25 February 2020.  

Significant Event Analyses are reflective tools that take place in all healthcare settings when there 
has been a significant event. They allow clinicians to review what has happened, understand what 
learning can be taken from the incident to prevent it happening in the future, sharing best practice 
and making sure that the recommended learning and the subsequent changes are put in place. 

As a result of the findings of the Significant Event Analysis, the practice has put in place several 
safeguarding changes from 25 February 2020.  

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Alert Note/Review System effective from 25 February 2020 
The practice has identified relevant existing patients by running reports for patients coded on the 
practice’s  clinical  system  as  using  neuropathic  medication,  cross  referenced  with  patients  coded 
with  alcohol  dependency  who  have  had  an  intentional  or  accidental  overdose.    A  “flag”  is  now 
placed on these patients’ medical records and a medication review is undertaken. The patients are 
then contacted to discuss their medication and their alcohol consumption. 

This process is managed by the Practice Manager who will run this report every three months to 
ensure  it  is  constantly  identifying  the  cohort  of  patients.    The  process  will  be  reviewed  at  these 
three monthly intervals and will evolve from any learning taken from them.  

The  process for  patients  who  may  unfortunately  suffer from  an  intentional/accidental  overdose in 
the future when the practice has been made aware of an overdose, is that the patient will be seen 
and reviewed by the Practice. Subsequently, in order to minimize the risks of future overdoses, all 
such  patients  will  be  placed  on  weekly  prescriptions.  The  practice  will  refer  patients  to  mental 
health services, social prescribing and drug and alcohol service as appropriate. 

To  further  support  this  process,  non-clinical  staff  have  been  trained  to  ensure  that  information 
related  to  intentional  or  accidental  overdoses  are  shared  with  the  General  Practitioners  in  the 
practice; so the process described above can be followed. 

Tameside and Glossop Clinical Commissioning Group (CCG) actions 

,  Director  of  Commissioning,  is  accountable  to  ensure  that  in  line  with  the 

Coroner’s request, the following actions will be undertaken: 

The CCG has developed the enclosed guidance to all practices regarding the identification 
and  management  of  patients  prescribed  neuropathic  drugs  and  opioids  that  may  also  be 
dependent  upon  alcohol  to  ensure  they  are  safely  managed.  This  has  been  sent  to  all 
practices electronically to be shared internally at their clinical meetings and for them to save 
on their electronic systems (June 2020) 

We shall keep these issues under review as part of the quality monitoring reported to the Strategic 
Commissioning Board, whose meetings are held in public.  Minutes are available on the Tameside 
and Glossop CCG website (https://www.tamesideandglossopccg.org/corporate/strategic-
commissioning-board). 

The  quality  of  care  in  primary  care  is  also  discussed  and  reviewed  at  the  following  monthly 
meetings: Primary Care Delivery and Improvement Group and Primary Care Committee.        

I  trust  that  our  actions  offer  reassurance  that  the  CCG  and  the  Practice  have  reflected  on  the 
evidence and findings provided at Mrs Wilkes’ Inquest.  It is acknowledged that there has been a 
great deal of learning and reflection following the Inquest of Mrs Wilkes and we assure you that this 
learning has been shared and disseminated. 

I  hope  this  brings  some  reassurance  that  we  are  working  to  ensure  another  tragic  loss  of  life 
doesn’t occur in similar circumstances.  

Please contact me if you require any further information or if I can assist further in any way.   

Yours sincerely 

Steven Pleasant MBE 
Chief Executive, Tameside MBC/Accountable Officer, Tameside & Glossop CCG 

Enc:  General  Practitioners  Guidance  document  regarding  patients  taking  opioids  and 
neuropathic drugs with alcohol dependency (June 2020)