Francis Cooney

University Hospitals Birmingham 
NHS Foundation Trust 

r.!1:~ 

Fo'r the attention of Emma Brown 
Area Coroner for Birmingham and Solihull 
50 Newton Street 
f;lirmil]gham 
Sent by way of email only:  birmingham.coroner@nhs.net 

5th October 2020 

Dear Ms Brown, 

Trust Headquarters 
Level1
Queen Elizabeth Hospital 
Mindelsohn Way Edgbaston
Birmingham
B152GW 

0121  371  2000 

Inquest touching the death of Francis Xavier Cooney 
Response to Regulation 28 Report to prevent future deaths 

I write in response to the Regulation 28 Report made by you following the Inquest into the 
death of Mr Cooney, which concluded on 5 August 2020. 

University Hospitals Birmingham NHS Foundation Trust (the Trust) has carefully considered 
the concerns raised within your report to prevent future deaths which  surround the 
communication with relatives/carers of those with cognitive impairment where changes are 
made to medication. 

Lasting Power of Attorney 

Following Mr Cooney's admission on 9 January 2020 it was identified that he lacked capacity 
to consent to surgical intervention to repair a wound to his scalp, as he was unable to retain 
the information surrounding the risks and benefits of the procedure.  Mr Cooney's daughter 
was present during the discussion and advised that she had lasting power of attorney (LPA). 
She agreed with the decision to proceed with surgery. 

In accordance with our Mental Capacity and Best Interests Procedure and Guidance 
document, Mr Cooney's daughter should have been asked to provide a copy of the 
registered LPA for Health and Welfare so that this could be reviewed and a copy placed on 
Mr Cooney's records.  Although it was documented that Mr Cooney's daughter held an LPA, 
a copy of the document was not requested. In the particular case of Mr Cooney, this would 
not have altered the decision making around the care that he received during this episode. 
Given that he had been assessed as lacking capacity, communication with the next of kin 
and/or carers regarding any changes in treatment were indicated whether an LPA was in 
place or not. 

Changes to medication 

During an in-patient stay clinical teams will discuss changes in medication with patients at 
the time of ward rounds,  administration and at the times of other assessments. In the context 
of the in-patient stay of a person without capacity, then best interests decisions may be 
made without necessarily contacting the next of kin, for example in the initiation of antibiotics 
to treat infection.  It is a clear expectation that any changes in medication prior to or on 
discharge will be communicated with the patient and / or their next of kin and / or their carer 
to ensure safe discharge. 

Chair; Rt Hon 

Chief Ellecutive: Dr 

 was of the opinion that the small reduction in dose of the sedative medications, 

Dr -
nltrazepam and amitryptiline, in the context of ongoing delirium, represented dose 
optimisation rather than a strategic change in medication. This is consistent with the 
which were in the 
measured concentrations of these drugs in the report from Dr 
therapeutic range. There was no change in the dose of the anti-depressant citalopram, in 
which the concentrations measured by Dr llllllllwere also consistent with therapeutic 
levels. 

Mr Cooney was admitted under the care of the plastic surgery team as a consequence of his 
scalp injury. He was reviewed during the admission by Consultant Geriatrician,  Dr -
because of concerns surrounding ongoing delirium. It is clear from the notes that her advice 
as to therapeutic changes of the above medication was acknowledged by the admitting 
team.  In this context it would be expected that the discharging team (plastics) would discuss 
all discharge medication with the patient and / or their next of kin and / or their carer as 
appropriate. Whilst the decision to reduce the medication was discussed with Mr Cooney, 
and it was considered at the time that he had understood the information provided, in light of 
his fluctuating confusion, it is recognised that Mr Cooney's daughter should have been 
informed of the changes that had been made and unfortunately this did not happen and this 
is a matter of regret.  We are satisfied that this was an unfortunate individual error and that 
there are processes in place to ensure discussion as to medications do take place 
appropriately on the discharge of patients. 

Medications provided on discharge 

I would not have expected the relatively small changes in medication to  have led to Mr 
Cooney's distress in isolation but this is on the basis that I would have expected his 
medication on discharge to have been contained in a blister pack, as it was on admission.  A 
blister pack contains separate sealed compartments for medications to be taken out at 
particular times of the day and this is of value for patients, such as Mr Cooney , with 
fluctuating  levels of capacity. 

However, as a consequence of our detailed review of Mr Cooney's last admission prompted 
by your letter,  it has now been determined that unfortunately Mr Cooney was not discharged 
with his medication in a blister pack but in individual packs. This information is different to 
that provided  by the nursing team, including in their evidence at the inquest.  This was an 
error and we wholeheartedly apologise for the evidence before the Coroner being incorrect 
in this regard.  It would  appear that the nursing staff who provided this evidence had  a 
genuine belief that Mr Cooney's medication was packaged in this way in light of the records, 
but it has emerged that this was an error, occurring within the pharmacy team. 

This issue,  i.e. the use of a blister pack, seems likely to be central to the subsequent sad 
events. 
On admission on 9 January 2020 it was correctly noted by the ward pharmacist that Mr 
Cooney was receiving his medication in a blister pack.  This is noted to ensure that there is 
consistency between admission and discharge so that the patient is discharged with an 
updated blister pack. Mr Cooney should have been discharged home with a blister pack, but 
this did not happen.  It is most likely that this is the error that contributed to Mr Cooney 
becoming confused and distressed regarding the tablets he needed to take when at home. 

A subsequent investigation by our Chief Pharmacist has identified that a note was made on 
the pharmacy system on 24 January that a blister pack was not required for Mr Cooney's 
take home medication.  This seems to have been an error, as there is no documentation of 
the rationale for such a decision which would be expected to have been recorded in the 

Chair: Rt Hon 

Chief Executive: Dr -

 event of such a change. The pharmacist who made the entry cannot recall whether,  or if so 
then how, a request to make this change was made. 

This error seems then to have been compounded by the fact that a need for a blister pack 
was not appreciated by the nurses discharging him.  Despite a clear icon, familiar to users 
(the B in front of the green cross in  Figure 1 below), located in the banner (a part of the 
electronic record that is always visible to the user), this discrepancy seems to have been 
missed.  At present, no individual can account for these errors,  which arose in series, and 
that is very much a matter of regret.  It is our intention to reinforce (as per below) the need for 
these medication issues, and the system prompts relevant to medication, to  be a matter of 
additional focus for both pharmacy and nursing staff on discharge. 

Action Plan 

We apologise unreservedly to the Coroner and  Mr Cooney's family that the evidence 
presented was inaccurate, but we are satisfied that this was a genuine error, which was in all 
probability influenced by the record indicating a need for blister packs. 

The first issue that we  have addressed is that the tragic events leading to Mr Cooney's 
suicide were not identified as requiring further internal investigation. We have implemented a 
system where any such event occurring within 28 days of discharge is identified to the Chief 
Medical Officer.  In particular our legal team will work with a named Deputy Medical Director 
to review the circumstances of the last admission where the cause of death is identified as 
suicide.  We anticipate that this will assist the Coroner and the family in  their understanding 
of relevant events. 

An action plan to  address the failure to obtain a record/copy of the LPA is being developed. 
A communication from  the Chief Medical Officer and  Chief Nurse will  be circulated, 
addressing the importance of the process to follow,  which  is set out within Trust policy, 
where an attorney has been appointed under a LPA for Health and Welfare and this will  be 
completed within the next 4 weeks.  In addition to the practical step of establishing a specific 
location for easy access to any LPA on the Clinical Portal component of our electronic 
healthcare record, we will be emphasising the importance of communication with both 
patient and family as appropriate.  This is in addition to the refresher work being done across 
the Trust as to  all aspects of the Mental Capacity Act and the protections afforded to patients 
without capacity,  either permanent or fluctuating. 

Secondly, a review of the process within our pharmacy team has taken place and we are 
satisfied that we have a robust electronic system to capture how medication should be 
provided to patients. A retrospective review of patients requiring a blister pack over the past 
12 months has been carried out.  There have been no similar incidents to the failure in 
regard to Mr Cooney's discharge blister pack,  we are reasonably confident this was an 
isolated incident of human error. 

Nevertheless,  in  light of this incident, our Chief Pharmacist has taken a number of steps to 
reduce the possibility of a similar incident occurring in  the future.  An email was forwarded  to 
our pharmacy team (covering all  4 sites) on  18 September 2020 sharing the learning from 
this case and reinforcing and reminding staff of the current processes that should  be 
followed  and that any clinical interventions or proposals, notable clinical conversations or 
decisions, must be documented. 

Having considered the concerns raised within  your report,  and the matters identified 
regarding an  apparent failure of the discharge process, we have put in  place a number of 
other actions to reduce the risk of a similar incident arising in the future. 

Chair;  Rt  Hon 

Chief Executive:  Dr

 We will be undertaking a refresh of training across all wards on the importance of 

1.  Review of medications on discharge with the patient 
2.  Communication of medications on discharge with the next of kin and I or their carer 

at the point of discharge 

3.  The importance of ensuring that the requirement for a blister pack is both recorded 

and actioned 

Finally,  I will communicate with the medical staff reinforcing the importance of 
communication with relatives and carers where patients have a cognitive impairment and the 
learning from this case will be cascaded through departmental clinical governance meetings. 

I would like to assure you that the concerns raised within the Regulation 28 Report have 
been taken extremely seriously which I hope is demonstrated in the steps we have taken in 
reviewing our systems and processes and raising awareness of the importance of clear 
communication and  I would again repeat our unreserved apology to you and Mr Cooney's 
family for the inaccurate information provided during the Inquest process. 

Yours Sincerely 

Professor -
Chief Medical Officer 

Chair: Rt Hon . 

Chief Executive: Dr -

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Chair: Rt Hon-

Chief Executive: D-

 Chair:  Rt  Hon 

Chief Exec:utive:  Dr