Michael Vince

High Street Surgery
219 High Street
Hornchurch

Essex

RM11 3XT

17 August 2022

Graeme Irving

Acting Senior Coroner

East London Coroner’s Service
Adult Learning College

127 Ripple Road

Barking |G11 7PB

Dear Mr Irving,

Re: Inquest Touching the Death of Mr Michael John Vince Regulation 28: Report to
Prevent Future Deaths

Thank you for sending the Prevention of Future Deaths Report regarding the death of Mr
Michael Vince, and providing me an opportunity to comment on the matters of concern
raised.

Before responding, | would like to express my sincere condolences to the family of Mr Vince
for their loss.

| have carefully considered the Report. Actions taken by myself and my practice in response
to the concerns raised are described below. ,

Concern 1:

The NICE quidelines for Zopiclone indicate that it is a suitable medication for the short-term
treatment of insomnia, it advises against prolonged use due to risk of tolerance and
withdrawal symptoms. Mr Vince is said to have been prescribed Zopiclone for 20 years.

Concern 2:

No evidence exists to support that Mr Vince’s GP or community mental health team
meaningfully reviewed his prescription for Zopicione.

Concern 4:

The frequency with which Mr Vince was administering his PRN Zopiclone was never monitored.

Page | of 3

Response to Concerns 1, 2 and 4

In response to the above concerns, the following actions have been undertaken:
A. Clinical Audit of all patients prescribed Zopiclone over the past 2 years:

The report contains concerns as to the monitoring and review of Mr Vince’s Zopiclone. In
response, our practice determined to undertake a comprehensive audit and clinical
review of all patients prescribed Zopiclone.

A review of practice records for all patients prescribed Zopiclone over the last 2 years was
performed. A summary of the results is as follows:

e Acute or one-off prescription of Zopiclone — 22 patients
e Repeat prescription of Zopicione — 16 patients

All patients currently taking Zopiclone were contacted for a structured medication review
undertaken by myself. The review was guided by best practice guidelines for the
prescribing of Zopicione. The result of the medication reviews was that the majority of
patients on repeat prescriptions had their repeat prescribing ended. Some patients were
referred to the Trust’s Mental Health Service for further review and management of their
Zopiclone administration.

After the initial structured medication review, a second cycle review of patients on repeat
Zopiclone prescriptions was undertaken. This showed that only 4 patients remained on
repeat Zopiclone. Two of these patients are scheduled for further review, and two remain
on long term Zopiclone and are scheduled for 6 monthly review.

B. Implementation of Z-Drug Protocol

| have drafted a local practice Protocol for Z-Drugs which has been implemented as at 29
July 2022. A copy of the Protocol is included with this letter.

The protocol was drafted following my review of best practice guidelines for the
prescribing and management of patients on Zopiclone and other Z-Drug hypnotics. The
protocol includes links to relevant NICE guidelines and a comprehensive resource pack
produced by the Greater Manchester Medicines Management Group included as an ©
appendix. It also includes a Good Sleep Guide to assist in advising patients with non-
pharmaceutical methods to manage insomnia.

The policy requires regular review of patients prescribed Z-Drug hypnotics being a
minimum of 4 weeks for newly prescribed patients, and at 6-monthly intervals for patients
on long term treatment and after review by Mental Health Services.

C. Discussion and Education of Practice Staff

Meetings have been held with practice staff to alert them t@ the new protocol, and to
advise them to refer all patients requesting repeat prescriptions of Z-Drugs to myself for
medication review.

Page 2 of 3

A notice has been placed in the practice waiting room for the information of patients
regarding the practice’s Z-Drug protocol.

We will continue to monitor the above actions in our regular practice meetings.
Concern 3:

Evidence of Mr Vince’s dependence upon Zopiclone was not shared by his GP with the mental
health trust.

Response to Concern 3

The North East London Foundation Trust (NELFT) Mental Health Service held a stakeholder
meeting on 14 July 2022 to discuss the Coronial recommendations, as well as the issue of
prescribing of Z-Drugs generally. The meeting included representatives from the NELFT
medication safety team. i was invited and attended this meeting which was a very useful
opportunity to discuss clinical collaboration with the Trust regarding patients on Z-Drug
hypnotics.

At that meeting the importance of proper communication between local GP’s, the NELFT
Mental Health Team and other clinical services was discussed. It was agreed that review of
hypnotics was the responsibility of the primary prescriber, but also the prescriptions should
be reviewed by the Trust clinicians when in the scope of treatment provided by that clinician.

The Trust committed to undertaking a wider audit of Z-Drug prescribing within the NELFT
localities which will be led by the Trust pharmacy services. They will also be developing a safe-
prescribing training package and will include education of local GP’s in their roll-out of this
package.

For my part, | have commenced more proactive referral of patients who appear dependent
upon Z-Drug hypnotics for review and advice by specialist NELFT Mental Health services. This
has been assisted by the response of the NELFT to the Coronial recommendations and the
discussion and collaboration that has resulted. My practice’s Z-Drug Protocol includes a
requirement for structured medication review for patients on long term Z-Drugs with mental
health issues, and a requirement to notify the Mental Health Team for those patients who
request additional 2 drugs.

Thank you again for your referring your concerns regarding the care of Mr Vince. If you would
like any further information regarding our response to the concerns, please contact me on

i

Yours Sincerely

Enclosed: High Street Practice Z-Drug Protocol

Page 3 of 3

PRIVATE & CONFIDENTIAL  
Mr Graeme Irvine 
HM Coroner 
The Adult College of Barking & Dagenham 
127 Ripple Rd 
Barking 
IG11 7PB 

Sent by email to:  
coroners@walthamforest.gov.uk; and  
@walthamforest.gov.uk 

Your ref:            G1/sc/14161785 
Our ref:              1127 

Dear Sir,  

Trust Head Office 
CEME Centre 
West Wing 
Marsh Way 
Rainham 
RM13 8GX 

 Tel: 0300 555 1298 

5 August 2022 

Re: Inquest touching upon the death of Mr Michael John Vince 

I refer to your letter dated 27th June 2022 and the Regulation 28 report, detailing your concerns 
related to the care provided by NELFT NHS Foundation Trust (‘NELFT’) as follows: 

1.  Mr Vince was prescribed with Zopiclone for 20 years, despite the NICE guidelines 

indicating that Zopiclone is not suitable for long term use.  

2.  There was no evidence that prescription of Zopiclone was meaningfully reviewed by 

NELFT’s Community Mental Health team or GP. 

3.  Evidence of Mr Vince’s dependence upon Zopiclone was not shared by his GP with the 

Trust. 

4.  The frequency with which Mr Vince was administering his PRN Zopiclone was never 

monitored. 

We have taken the concerns expressed by you very seriously and undertook further consultations 
with the Chief Pharmacist and other members of the MDT. On 06/07/22 we arranged a wider 
NELFT learning review led by our pharmacy department and developed an action plan to address 
the  identified  further  learning  following  the  Inquest.  The  event  was  attended  by  health  care 
professionals at NELFT and primary care including the practice which was directly involved in the 
care of Mr Vince. 

Chair: 
Acting chief executive: 

www.nelft.nhs.uk 

 
                             
   
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 The  current  practice  at  NELFT  is  that  whoever  prescribes  the  medication,  is  responsible  for 
monitoring the compliance with medication administration regime. However, in light of learning 
from this inquest we have updated our practice as highlighted within the attached action plan and 
will monitor implementation of the updated practice jointly with the chief pharmacist. 

We have agreed a number of actions to address concerns raised by you and enclose action plan 
detailing the Trust’s efforts to improve the safety and quality of care provided by NELFT.  

I would like to express my heartfelt condolences to the family of Mr Vince and sincerely apologise 
for the shortcomings in care provided by NELFT identified in our Serious Incident report as well 
as at the inquest hearing on 21st June 2022.  

I would also like to thank you for your full and fearless investigation and for raising your concerns 
with the Trust, enabling us to undertake further learning from the very sad death of Mr Vince.   

If you would like to discuss these actions further, please kindly feel free to contact my office on 
0300 555 1298. 

Yours Sincerely 

Chief Executive Officer (acting)   

Chair: 
Acting chief executive: 

www.nelft.nhs.uk