Eirwen Hollister

Heathview Medical Practice 

Glascote  Health Centre, 
60 Caledonian, 
Glascote 
Tamworth 
Staffs.  B77  2ED 

Stonydelph Medial  Practice 
55 Ellerbeck, 
Stonydelph, 
Tamworth 
Staffs.  B77 4JA 

Wilnecote Surgery 
Parson  Street, 
Wilnecote 
Tamworth 
Staffs. 

B77 5BO 

4m  November, 2022 

Coroner's Office, 
1 Staffordshire Place, 
Stafford. 
ST16  2LP 

Dear Sirs, 

RE;  REFERENCE ARB/EAS 12533072 

Further to your recent correspondence  regarding the above please find the enclosed:-

!.  Report following the inquest to prevent future deaths 

2.  Significant Event Analysis 

3.  Overdose Policy 

Yours faithfully, 
Heathview Medical Practice 

Partners 

 
 
 
 
 .I 

REPORT  FOLLOWING  CORONER'S INQUEST TO  PREVENT FUTURE  DEATHS 

The  Heathview Medical Practice, Tamworth have been  requested to provide a report following the 

coroner's inquest into the death of Eirwen  Rebecca  Hollister. 

Circumstances of the Death : 

This  patient was  registered at Heathview Medical Practice in Tamworth but was also simultaneously 
registered at Sutton Coldfield group Practice between 21 st  September 2021 and end of February 
2022. She was  receiving medication from both practices during this time. To  date there is  no clear 

explanation how this has occurred. 

On  21st March 2022 she took an overdose, was  assessed  by paramedics at her home, and declined 
admission. She undertook a further overdose on  22 nd  April 2022 and was  taken to Good Hope 
Hospital and discharged on  24t h  April  2022 . 

During the time between the overdoses she  was  prescribed  weekly medications but was  not 

reviewed  by the practice. 

She was found deceased at her home address on  10th  May 2022 . 

Concerns raised: 

•  The  practice has a clear policy concerning overdoses, which states that medications will be 

switched to weekly issues and the patient has to be reviewed  by a clinician before issuing of 

medication. In this case the medication was  issued  weekly, however the patient was  not 
reviewed following the overdose. 

•  The  patient was  registered at two different GP  Practices simultaneously and receiving 

medications from  both  Practices. 

Actions taken by  practice: 

•  We have carried out a significant event analysis to identify any failings and learning points. 

The  results of the significant analysis were discussed  with all clinicians in  a meeting on 
21/10/22. Please find attached a copy of the significant event analysis. 

•  The  'Overdose Policy'  has  been  reviewed and  discussed with all clinicians at Heathview 

Medical Practice on  21/10/22 . The  Policy is  on  the shared drive and  can  be accessed  by all 
staff. Please find attached a copy of the Policy. 

•  Teaching has  been carried out to all clinical staff on  how to action Docman  letters (Clinical 

letters from  Hospital) which  involve overdoses on  21/10/2022 

•  The Policy and the significant event will be  discussed with all the staff in  a practice meeting 

on  15th  November 2022 

•  We have contacted NHS registrations; however, they could  not explain how a patient 

managed to register at two different practices simultaneously and are looking into this. 

Conclusion 

The  Practice will continue to be transparent and  abide by its duty of candour. 

 Although there is  a clear policy in  place concerning overdoses, which consists of two parts (switching 

to weekly medications and  reviewing the patient before medications issued), the first part of the 

policy was followed but not the second  part. 

Significant event analysis,  policy review, teaching, and  discussion has  been carried out to prevent 

recurrence of this event and to ensure all  parts of the policy are followed. 

On  behalf of Heathview Medical Practice, Tamworth . 

 SIGNIFICANT EVENT ANALYSIS 

PRACTICE NAME:  Heathview Medical  Practice 

DATE OF  MEETING :  11.10.2022- 24/10/22 

MEETING ATTENDEES:  GP Partners,  PM, Assistant PM, Associate  Partners 

DATE OF INCIDENT  10/5/22 (21/3/22, 22/4/22) 

TIME OF  INCIDENT 

SIGNIFICANT EVENT RAISED  BY:-

IWHICH  OF THE FOLLOWING  BEST  DESCRIBES THE INCIDENT? 

Prescribing, 
Dispensing 
X 
Medical 
Records X 
WHAT HAPPENED? 

Vaccs  & lmms  H/Vs, OOH, 
Emergencies 

Confidentiality  Secondary 

Care 

Communication 
within 
team/external 
Violence & 
Aggression 

Path 
Reports 

Other 

Appointments 

This patient was  registered at Heathview Medical 
Practice  in Tamworth but was also simultaneously 
registered at Sutton Coldfield group Practice 
between 21st September 2021 and end  of February 
2022. She  was  receiving medication from both 
practices during this time. To  date there is no clear 
explanation how this has occurred. 
On  21st March 2022 she took an  overdose, was 
assessed  by paramedics at her home, and declined 
admission . She  undertook a further overdose on 
22nd April  2022 and was taken to Good  Hope 
Hospital  and  discharged on 24th April 2022 . 
During the time between the overdoses she  was 
prescribed weekly medications but was  not reviewed 
by the practice. 
She  was found deceased at her home address on 
10th May 2022. 

Practice Policy concerning overdoses: 1. Switch to 
weekly medications 2.  Patient to be reviewed before 
issued . 
Weekly medications in  place but patient was  not 
reviewed . 

The  patient had been  reviewed by paramedics and 
also  by the hospital who had stated that patient was 
not suicidal. The clinicians from the practice relied 
on this rather than carry out their own reviews. 

WHY DID IT HAPPEN 

 
 WHAT WAS DONE WELL? 

Weekly medications. 
Alerts were put on the patient notes 
Regular reviews had been carried out prior to the 
last two overdoses 

WHAT COULD HAVE BEEN  DONE DIFFERENTLY AND 
WHO WAS INVOLVED IN THE  DISCUSSION 

Patient should have been  reviewed before 
medication issued as  per practice policy. 

WHAT HAVE YOU AND YOUR TEAM  LEARNT? 

WHAT CHANGES  HAVE YOU OR THE 
ORGANISATION  MADE? 

Although Policy in  place the patient was  not 
reviewed. 
The patient had been reviewed by paramedics and 
also by the hospital who had stated that patient was 
not suicidal. The clinicians from the practice relied 
on  this rather than carry out their own reviews-
Clinicians should not rely on  this and adhere strictly 
to the policy of the practice. 

This case  has  been  discussed  with all clinicians at the 
practice . 
The  Policy has been  reviewed and teaching carried 
out on this. 
Docman  (clinical letters from Hospital) teaching and 
training has been carried out at the practice. 

OTHER COMMENTS/REVIEW DATE IF APPLICABLE 

The above actions taken should  prevent recurrence. 

 Heathview Medical Practice 

Policy Regarding Overdose 

Introduction 

This policy is regarding patients who have presented with overdose.  They may have  been 
discharged from hospital or seen  by any other service. 

AThe practice will: 

1.  Switch medications to weekly medications upon receipt of overdose notice. 
2.  Patient is to be reviewed by a clinician before medication is issued . 

3.  Alert to be added on to records. 

Next review October 2024

Ms E Serrano 
HM Area Coroner for Stoke-on-Trent and  
North Staffordshire 
Stoke Town Hall 
Kingsway 
Stoke-on-Trent 
ST4 1HH 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

31 January 2023 

Dear Ms Serrano 

Re: Regulation 28 Report to Prevent Future Deaths – Eirwen Rebecca Hollister 
who died on 10 May 2022 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  11 
October 2022, concerning the death of Eirwen Rebecca Hollister on 10 May 2022. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Ms Hollister’s family and loved ones. NHS England 
are  keen  to  assure  the  family  and  the  coroner  that  the  concerns  raised  about  Ms 
Hollister’s care have been listened to and reflected upon.  

We also would like to take this opportunity to thank you for your continued support in 
allowing  an  extension  of  the  deadline  date  for  our  response.  This  has  been  a  very 
complex case and the extra time was essential in enabling a full and robust response.  

Following the inquest, you raised a Matter of Concern that:  

NHS registration could not explain why a patient, with a history of prescription drug 
abuse, had managed to, and continued to be, registered at two GP practices. Thus, 
allowing this patient to obtain two prescriptions of each medication at a time.  

This  response  has  been  prepared  following  investigations  supported  by  key 
stakeholders  including  NHS  England,  Staffordshire  and  Stoke-on-Trent  Integrated 
Care  System,  Birmingham  and  Solihull  Integrated  Care  System  and  NHS  patient 
registrations.  

Dual GP registration is not supported by NHS England, given the unacceptable patient 
safety  risks  arising  from  duplicate  offers  of  care  including,  for  example,  in  the 
prescribing of medicines or the delivery of other treatments such as vaccinations. Only 
one GP practice can access and add to and amend medical records at one time.  

Patients can be deducted from practice lists due to:  

• 

the patient moving out of area and the practice not wishing to treat the patient 
under the Out of Area Scheme 

                                                                                                                       
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 •  mail returned as “undelivered” 
• 

the patient’s whereabouts are unknown 

NHS  England  directs  that  all  deductions  are  processed  via  Primary  Care  Support 
England (PCSE). When GP practices update patient registration information on clinical 
systems,  PCSE  uses  that  information  to  update  National  Health  Application  and 
Infrastructure  Services  (NHAIS).  NHAIS  is  the  IT  system  that  holds  the  National 
Patient  Register,  which  is  used  to  call/recall  patients  for  national  screening 
programmes. When NHAIS is updated, changes are fed through and made to patient 
demographic  data  held  on  the  Personal  Demographics  Service  (PDS)  on  the  NHS 
Spine.  

Following  local  investigations,  it  has  been  identified  that  Ms  Hollister  was  not  dual 
registered at both practices at the same time. However, it appears that she was “dual 
consulting” with clinicians at both practices between September 2021 and February 
2022. At the time of her death, Ms Hollister was only registered at Heathview Practice 
in Tamworth (February 2022 – May 2022) and was not registered or receiving care 
from the Sutton Coldfield Group Practice. 

Ms  Hollister  was  previously  a  permanent  registered  patient  at  the  Sutton  Coldfield 
Group Practice between September 2021 and February 2022, during a time when she 
moved to the Sutton Coldfield area. A review of audit records has confirmed that Ms 
Hollister’s medical records were transferred between Heathview Medical Practice and 
the Sutton Coldfield Group Practice within a few days of the new registration via GP 
Link, and all secondary care admission/discharge letters were received by the Sutton 
Coldfield  Group  Practice.  However,  during  this  time,  Ms  Hollister  also  consulted  at 
Heathview Medical Practice nine times. 

We  are  aware  that  SystmOne  has  features  such  as  alerts  when  accessing  patient 
records for patients who are no longer registered at the practice, and it provides details 
of  all  consultations  /  contacts  and  prescriptions  given  at  other  healthcare  facilities 
outside of that GP practice. Despite this and a detailed investigation, it has not been 
possible  to  answer  how  Ms  Hollister  was  able  to  consult  with  both  practices  at  the 
same  time,  without  this  flagging  on  either  system.  Possible  hypotheses  have  been 
investigated and ongoing work is being completed to identify if any digital or system 
improvements are needed or possible.  

Locally, in response to the incident, Heathview Medical Practice have undertaken a 
significant event audit which has resulted in an update to the practice’s local policy on 
management of hospital letters. A teaching event has also taken place with all practice 
staff on the importance of read coding, which is the standard vocabulary for clinicians 
to record patient findings and procedures in health and social care IT systems, and 
ensuring urgent reviews of patients who self-harm or overdose. 

Heathview  Medical  Practice  have  also  produced  a  new  policy/procedure  on  patient 
registrations and deductions and have introduced a new dedicated team to manage 
patient registrations within the practice. EMIS training on registrations is also planned 
for March 2023.  

 
 
 
 
 
 In addition, the Integrated Care System (ICS) hosting the Heathview Medical Practice 
(Staffordshire and Stoke-on-Trent ICS) working with system partners to look at wider 
learning, including areas such as pharmacy dispensing.  

Regionally, where applicable, learning will be shared across the region and nationally 
from this case using established communication channels within NHSE. 

I would also like to provide further assurances on the national NHSE work taking place 
around the Reports to Prevent Future Deaths. All reports received are discussed by 
the Regulation 28 Working Group, comprising Regional Medical Directors and other 
clinical and quality colleagues from across the regions. This ensures that key learnings 
and insights around events, such as the sad death of Ms Hollister, are shared across 
the NHS at both a national and regional level and helps us to pay close attention to 
any emerging trends that may require further review and action. 

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, 

National Medical Director  
NHS England