Nora Foulkes

Bloc 5, Llys Carlton, Parc Busnes Llanelwy, 
Llanelwy, LL17 0JG 

---------------------------------- 

Block 5, Carlton Court, St Asaph Business 
Park, St Asaph, LL17 0JG 

Ein cyf / Our ref: JW/MJ/DL/3115 

Eich cyf / Your ref:    
:   
Gofynnwch am / Ask for:    

E-bost / Email:  
Dyddiad / Date: 10th June 2022  

Mr John Gittins  
Senior Coroner 
North Wales (East and Central) 
Coroner's Office 
County Hall 
Wynnstay Road 
Ruthin  
LL15 1YN 

Dear Mr Gittins 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 
Nora Jane Foulkes 

I write in response to the Regulation 28  Report to Prevent of Future Deaths issued by 
yourself to Betsi Cadwaladr University Health Board, following the inquest touching the 
death of Nora Foulkes.  

I would like to begin by offering my deepest condolences to the family and friends of Mrs 
Foulkes, and I apologise for the concerns identified at the inquest that have given rise to 
your notice.  

In  your  Notice,  you  raised  concern  that  although  the  original  failure  to  restart  the 
deceased’s treatment for her hypothyroidism would appear to have been discussed and 
agreed  between  the  Advance  Nurse  Practitioners  (ANPs)  and  the  care  home  when  a 
medication review was conducted, the deceased was subsequently seen by ANPs on six 
more occasions between then and her subsequent admission to hospital and as a result 
there were multiple opportunities for this error to be spotted and corrected but this did not 
happen because at those visits there was no consideration being given by the ANPs to 
the patient’s medication regime to ensure that appropriate treatment was being provided. 

In response, I can advise that a safeguarding referral has been made and that we have 
undertaken an internal review of the staff involved. The findings of this review have been 
shared with the Local Authority Safeguarding Team. They have confirmed to us, on 19 
May 2022, they are taking no further action as they are satisfied with the lessons learned 
and actions taken in relation to staff and wider learning which is detailed below, such as 
improved record keeping and medication reviews. 

The best practice guidance is under review for Advanced Nurse Practitioners (ANP) and 
a regular quality improvement meeting for Independent Nurse Prescribing, chaired on a 
Health  Board  wide  level  by  the  Deputy  Executive  Director  of  Nursing,  is  held  where 
learning is disseminated on a monthly basis. We expect the review to be completed by 
30 September 2022 and the learning and any changes to practice as a consequence will 
be disseminated through this meeting structure and agenda. 

Ysbyty Gwynedd, Penrhosgarnedd 
Bangor, Gwynedd LL57 2PW 

 / Executives’ Office 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A rolling training programme facilitated by the medicines management nurses is in place 
and  open  for  all  nursing  and  residential  homes  across  the  Health  Board.  Attendance 
records are kept for each training session. 

Due to the incident not being reported at the time, a formal review was not undertaken or 
reviewed by the Health Board’s Incident Learning Panel. We will conduct a formal internal 
investigation to identify root causes and lessons learned.  Which will be disseminated to 
all district nursing teams. This will be completed by 30 June 2022.  

Concern was also noted that whilst ANPs could access medication charts if required, this 
was not being done routinely. I can advise changes have been made to the way the local 
District  Nursing  team  in  the  Ruthin  and  Corwen  locality  work,  which  incorporates  a 
documented medication review at each visit. A check list has been developed to prompt 
clinical  staff 
including  medication 
changes/administration.  The checklist is initialled by both the visiting nurse and the home 
manager/deputy.  The checklist forms part of the patient’s individual nursing record for 
review and auditing. 

review  key  criteria  at  each  visit, 

to 

The learning from this matter, including the medication review issues identified above, 
will be checked across all district nursing teams to ensure consistent practice across the 
Health Board. We will survey all teams to assess their level of compliance. This will be 
completed by 30 June 2022. 

Following  this  survey,  all  district  nursing  teams  will  develop  (or  review  and  adapt)  a 
Standard  Operating  Procedure/checklist  to  meet  the  needs  of  their  own  services  that 
provides assurance of medication reviews. This will be completed by 31 December 2022. 
We  will  discuss  with  our  Clinical  Effectiveness  Team  how  this  can  be  audited  over  a 
longer period of time, to ensure that we have ongoing assurance that the changes have 
been embedded and sustained.  

We also note your concern that the absence of proper scrutiny or review of the medication 
of elderly patients in care homes during each visit presents a risk as it can lead to the 
type of error which occurred in this case not being identified.  

In response, I can advise that we have taken the following steps: 

As above, the local district nursing team now conducts medication reviews at every visit, 
which is documented and countersigned by the home manager (or their representative).  

The Health Board Policy (MM03) includes audit of prescribing as a standard for all nursing 
managers and independent prescribers. The Corporate Nursing Team has initiated a task 
and finish group to plan the launch of the most recent ratification of MM03 in July 2022 
which  will 
Independent  Prescribing 
responsibilities.  

re-education  of  managers  and 

include 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 All ANP prescribers are required to sign an annual declaration of compliance.  This is 
stored  on  a  centralised  database  and  is  reviewed  as  part  of  annual  performance  and 
development appraisals. 

The Health Board medicines management nurses carry out audits within care homes – 
although  this  does  not  specifically  scrutinise  prescribing,  it  covers  storage  and 
compliance  with  administration  in  care  homes  identified  as  being  in  escalation  at  the 
request of the care homes team. 

Further learning and action includes: 

  The  Health  Board  will  undertake  a  review  of  the  Medicines  Policy  (MM01)  and 
other related policies to clarify the process of prescribing in community settings, 
including  clarity  around  the  non-medical  prescribers’  roles,  responsibilities  and 
follow up arrangements. This will be completed by 30 September 2022.  

  Medication administration training  will be delivered to all residential and nursing 
home settings. The Heads of Primary Care in collaboration with the Area Nurse 
Director  will  complete  and  submit  a  business  case  for  the  required  investment.  
The  existing  IMTP  bid  will  be  escalated  back  to  executives  for  consideration  of 
regional funding. 

  An  audit  of  the  existing  rolling  training  programme  will  be  developed  to  identify 
homes where training is incomplete or out of date this will include the introduction 
of a compliance matrix to enable training compliance to be reviewed in real time.  
This will be completed by 30 September 2022. 

  A  proposal  has  been  developed  (currently  under  review)  for  the  Central 
Community Pharmacy team to work more collaboratively with the Central (Area) 
Community  Resource  Team  (CRT)  which  will  include  regular  structured 
medication reviews for nursing and residential home patients.   

  A Welsh Government pilot project has been developed (for future implementation) 
with a view to community pharmacy carrying out medication reviews of patients in 
care homes. 

I hope my letter offers you assurance that we have worked to address the concerns you 
identified.  

One again, please may I offer my condolences to the loved ones of Mrs Foulkes. 

Should  you  require  any  further  information  or  evidence  of  the  actions  outlined  above 
please contact either myself or Matthew Joyes, Associate Director of Quality.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely 

Prif Weithredwr/Chief Executive