Beatrice Dawkins

r~1:b1 

Portsmouth Hospitals 
University 
NHS Trust 

Trust Headquarters 
F Level, Queen Alexandra Hospital 
Southwick Hill Road 
Cosham 
PORTSMOUTH, PO6 3LY 

Tel: 

Dear Mr Pegg, 

Response to Regulation 28 report to prevent future deaths following the inquest into 
the death of Beatrice Dawkins 

I write to provide the Trust's response to your regulation 28 report issued following the 
inquest into the death of Beatrice Dawkins. For ease of reference the matters of concern 
identified by you during the inquest as described in the report are as follows: 

. 

The deceased's medical records contained at least seven entries indicating the deceased 
had a sensitivity to chloramphenicol,  the first such entry being recorded in  1997. 

Those medical notes included notes made by the Queen Alexandra Hospital, Portsmouth in 
which the deceased's recorded allergies included chloramphenicol. 

Evidence was adduced that had the clinicians involved in the care and treatment of the 
deceased in September 2020 had knowledge of those notes and/or the deceased's 
sensitivity to chloramphenicol had been flagged in the medical records during the 
deceased's September 2020 admission, chloramphenicol would not have been prescribed to 
the deceased. 

My concern is that relevant, critical information relating to the care and treatment of the 
deceased was in existence but was not accessible nor flagged up to those involved in the 
care and treatment of the deceased. 

In the absence of a process where relevant,  critical information is accessible or flagged up to 
clinicians,  there continues to be a future risk to life. 

Trust Response 

The risk of mis-transcription of allergies and drug sensitivities is increased by the manual 
completion of drug charts,  requiring the prescriber to identify historical allergies from 

Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, 
P06 3LY 
Registered charity number: 1047986 

Working  To drive excellence in care for 
together our patients and communities 

 
 
 
 r~1:b1 

Portsmouth Hospitals 
University 
NHS Trust 

available records, including GP referral  letters, and document them accurately on the new 
drug chart. The records from which this information is obtained for all non-elective 
admissions are held electronically, either in the form of historical outpatient correspondence 
and discharge summaries, or through the Care and Health Information Exchange (CHIE). 
CHIE is populated by primary care held information and accessible to the hospital clinical 
teams where a patient has given consent for their records to be included on the system. 
CHIE is probably the most reliable  resource for allergy identification available to admitting 
clinicians who are normally working under significant time pressure, followed by previous 
discharge summaries. The pharmacy team also have access to the Summary Care Record 
(SCR) which provides an additional resource for reviewing community records. It is not 
possible for doctors, other prescribe rs, or the pharmacy team to go through every historical 
electronic and paper record available for each patient due to the realistic time constraints 
present for all practitioners in a modern acute healthcare system. Thus, where an allergy has 
not been transcribed into CHIE or SCA and is not mentioned within recent hospital derived 
medical correspondence, risk arises of the sort demonstrated in this case. 

As was described in the evidence adduced at the inquest, an Electronic Prescribing and 
Medicines Administration (EPMA) system is currently being rolled out to every inpatient ward 
across the Trust and the Emergency Department. It has already been rolled out across 
medicine and will be extended to all wards across the Trust by the end of 2022. This system 
will retain information regarding any previous documented allergies or drug sensitivities and 
will provide that detail automatically when any new prescription is commenced to support 
future admissions. There is also a requirement to specify the nature of the allergy at the 
point it is documented. The data on drug allergies and sensitivities are flagged up 
prominently whenever the electronic drug chart is being reviewed, when new medicines are 
being prescribed, and when medicines are being administered by the nursing team.  If the 
prescriber overrides an allergy or interaction, they will need to state a reason for why this 
has been done, which is logged and fully auditable. This will significantly reduce the risk of 
drug allergies not being identified going forwards. 

Inpatient discharge summaries are sent electronically to GP practices.  With the introduction 
of EPMA the medicines component of those summaries will now be populated by the EPMA 
system to improve their accuracy. For medicines this will  require the prescriber to select the 
medication to appear on the discharge summary, for allergies this will pull through 
automatically. It is already recommended to our teams that any new allergies should be 
flagged in the GP Actions section of the discharge summary to ensure that they are 
translated effectively into the primary care patient records. To further reinforce this, we will 
be making a change to the discharge summary template with the support of the DigiMeds 
team (the team supporting the introduction of EPMA into the Trust), to include this as an 
option. We will also be looking to remove the 'no action' option to promote clear recording. 

Identification of allergies and adverse drug reactions (ADR) is a national focus for the NHS 
with NICE guidance on drug allergies aiming to improve the sharing of allergy and 
medication intolerance data across the health service in  England. An NHS Commissioning 

Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, 
P063LY 
Registered charity number: 1047986 

Worki~ To drive excellence in care for 
together our patients and communities 

 
 r,•t:k1 

Portsmouth Hospitals 
University 
NHS Trust 

for Quality and Innovation incentive (CQUIN) for 2022-23 is currently being deployed to 
promote the Transfer of Care Around Medicines (TCAM). TCAM requires the pharmacy 
team within Acute Hospital Trusts to communicate any high-risk patients to their community 
pharmacy, for example if a new drug allergy has been identified. This information will be 
transmitted electronically and stored on the records of the community pharmacy for that 
patient. The presence of this information held within the database of the community 
pharmacy will increase the opportunity for the GP practice to obtain that information and 
record it on their own systems. PHU Trust will be supporting this transfer of information using 
the PharmOutcomes platform. 

A key requirement to prevent further cases of this type, is to work with primary care to 
ensure that the GP records can be as complete as possible in relation to Adverse Drug 
Reactions (ADR) including allergies. To support that in Portsmouth and Southeast 
Hampshire (PSEH), we will share the learning from this case with  local GP practices to 
reinforce the need for allergies reported by the hospital to be cross referenced with Primary 
Care records when patients are discharged. In the case of Mrs Dawkins, the allergy reported 
by the patient during previous hospital appointments was included within written 
correspondence to the GP but was still not added to the GP record.  If this had been done, 
then the Chloramphenicol sensitivity would have been available on the GP record and thus 
would have been transcribed over to the drug chart either by the admitting doctor or through 
medicines reconciliation by the pharmacy team. 

Handheld severe allergy cards will also be developed and made available within PHU for 
patients who have difficulties remembering their allergies or who have multiple significant 
allergies.  Upon development, these cards will be shared with the Hampshire and Isle of 
Wight Medication Safety Group as recommended best practice for wider adoption. 

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In addition to the actions taken locally, there is a national Information Standard being 
developed by NHS Digital looking specifically at medicine and allergy/intolerance data 
transfer between care settings. 

Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, 
P06 3LY 
Registered charity number: 1047986 

Workir-g  To drive excellence in care for 
together our patients and communities 

..  .  ,, .  .. , . 

 
 r~1:k1 

Portsmouth Hospitals 
University 
NHS Trust 

The initiatives described will significantly reduce the risk of a recurrence of Mrs Dawkins 
case, both immediately and into the future. Given the number of patients that the hospital 
cares for each year, the complexity of the information pertaining to them and the fact that the 
accuracy of its recording is subject to human error on occasions, unfortunately it will not be 
possible to completely eradicate the possibility of an episode of this type occurring again. 

However, I hope that the information contained within this response provides you with the 
assurance you need that PHU is taking all reasonable steps to minimise that possibility. 

Yours Sincerely 

Chief Executive 

Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, 
P06 3LY 
Registered charity number: 1047986 
· . / · 
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Worki~ To drive excellence in care for 
together our patients and communities 

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