Sally-Ann Few

Medway Maritime Hospital 
Windmill Road 
Gillingham 
Kent 
ME7 5NY 

OFFICE OF THE CHIEF MEDICAL OFFICER 

10th January 2023 

Ms Catherine Wood 
Assistant Coroner 
Mid Kent and Medway Coroners 
Cantium House 
County Hall 
Sandling Road 
Maidstone 
Kent 
ME14 1XD 

Dear Ms Wood, 

Prevention of Future Deaths Regulation 28 Report 
Sally-Ann Few (Sally-Ann Bester) 

We refer to your report issued following the inquest touching upon the death of Sally 
Ann Few dated 15th November 2022 pursuant to Regulation 28 of the Coroner’s 
(Investigations) Regulations 2013. 

Background: 
Sally-Ann Few had a past medical history of chronic obstructive pulmonary disease, 
entrocutaneous fistula, chronic gastric ulcer, pulmonary embolism, depression with a 
previous paracetamol overdose in 2020 and alcohol dependence. She had a 
prolonged hospital admission from July 2021 following a perforation of her gastric 
ulcer leading to months in hospital and necessitating intubation and a tracheostomy. 
She was discharged home and a medication review conducted by a community 
pharmacist on 15th December 2021 led to a decision to change her Oromorph to 
slow-release Zoromorph. A review by the same pharmacist led to discontinuation of 
the Oromorph and she was maintained on the slow-release prescription alone as her 
pain was under control. 

Sally-Ann was readmitted to hospital on 1st March 2022 with a deterioration in her 
breathing, shortness of breath and biphasic stridor which led to a diagnosis of 
cricoarythenoid fixation due to her period of prolonged intubation 

Pharmacy reviewed and completed a drug history of the patient’s medication on 
Thursday 3rd March.  This drug history was completed using sources of the patient, 
patient’s medication, and the Kent Summary of Care record (this is in accordance 
with the current Trust Medicines Reconciliation Policy). This established that the 
patient was prescribed and had been taking Morphine preparations prior to hospital 
admission as well as a number of other medications including citalopram.  

There was one issue identified during the drug history, Oramorph (short-acting 
morphine sulphate 
chart at a dose of 

twice a day. The patient was normally prescribed Zomorph 

liquid preparation) had been prescribed on the drug 

 
 
 
 
 
 
 
 
 
  
 
  twice a day.  The 

(long-acting morphine sulphate capsule preparation) 
pharmacist addressed this issue on Tuesday 8th March, documenting in the notes 
that the prescribers needed to review the switch.  However Sally-Ann continued to 
receive Oramorph until discharge.  Her final dose of Oramorph 
Friday 11th March.  The discharge letter shows that on discharge Oramorph 
twice a day was ceased and changed to 
required.  Zomorph was restarted at a dose of 
are the same dosages Sally-Ann was prescribed on admission according to the 
documented drug history. 

 every four to six hours when 
 twice a day.  These dosages 

 was 8:00am on 

She was provided with 
 of Oramorph and 2 weeks supply of Zomorph. She 
was found dead at home on the morning of the 12th March 2022 and the bottle of 
morphine she had been discharged with was nearly empty 

The following is our response in relation to the matters of concerns raised:  

1.  Evidence given at the inquest revealed that the system at the GP 

practice when examined by the pharmacist at the hospital did not show 
that the Oromorph prescription had been stopped. 

This observation relates to a potential discrepancy between the information 
held on the GP record which feeds information into the Kent Summary of Care 
Record (used as a data source for medicines reconciliation on admission) and 
the adjustments to morphine regime subsequently undertaken by the primary 
care pharmacist.  

The Trust Pharmacy team has contacted representatives of the Kent & 
Medway ICB Medicines Optimisation team that cover Medway & Swale. They 
are currently investigating the review process by the pharmacist to understand 
how the dose and product changes made were recorded and communicated 
to the GP practice. They are also investigating why these changes did not 
appear in the Kent Summary of Care Record. 

2.  Evidence was heard that Mrs. Few whilst an in patient was prescribed 

Oromorph and not Zoromorph the drug she had been using at 
twice a day. The effect of which may have impacted upon her pain 
control but the evidence did not show she had high pain scores. A 
pharmacist recognised this discrepancy on 8th March and asked for this 
to be reviewed. No such review took place and it was difficult to see on 
the electronic records system that such a review needed to take place 
as apparently there were no highlights or flags to alert the doctors that 
such a review needed to take place. 

The Trust implemented an Electronic Patient Record (EPR) system in 
November 2021 and an Electronic Prescribing & Medicines Administration 
(EPMA) system in September 2022. 

The EPMA system is being continuously developed and enhanced to improve 
patient safety, and whilst there is a section now included for Pharmacists to 
add notes to electronic prescriptions, the Trust is seeking to develop 

 
 
 
 
 
 
 
 
 
 functionality that would create a warning alert that would trigger a review by a 
doctor. The system is fully auditable and will identify who triggered the action, 
when it was viewed and what response is made. A feasibility meeting is being 
booked for key stakeholders at the beginning of January 2023. 

In the interim, Pharmacy staff have been reminded that their professional 
responsibility does not end with a note flagging a potential medicines issue, 
but there is an expectation that recommendations should be followed through 
to a conscious decision to either endorse or reject a recommendation. 

As a collaborative approach, the Trust Pharmacy team and ICB Medicines 
Optimisation teams have agreed to present the information in the form of a 
case study to Pharmacy colleagues at a future meeting of the Controlled Drug 
Local Intelligence Network (CDLIN) to share learning 

3.  At the inquest it was clear that the standard of record keeping by the 
medical staff was poor and it was only by hearing from witnesses via 
statements and orally, including from her family, that the decision 
making around her care and plans for her management became clear, as 
there was very little written in the notes. In particular there was no 
evidence of why decisions were made, what discussions were held and 
what advice was given. 

Sally-Ann Few (Sally-Ann Bester) was seen by either a consultant or another 
senior ENT doctor on a daily basis during her inpatient stay as part of the 
daily ward rounds. The daily decisions taken regarding treatment of her 
airway condition were documented. The reasons for the decisions were clear 
to the treating team, but may be less clear to clinicians and others who were 
not team members and the ENT clinicians have been reminded of the need to 
both continue to document decisions on the daily ward round and additionally 
document the reasons why the decisions were made. The electronic 
discharge summary completed on 11th March 2022 did explain the decision 
making process and the options that had been discussed. It is acknowledged 
that the medical notes did not include any discussion regarding opiates as the 
ENT medical team’s understanding throughout the admission was that the 
prescribed opiates were those which were being taken on admission.  

We thank the Assistant Coroner for raising this with us and highlighting the 
opportunity for an improvement in our process. 

Yours sincerely,  

Chief Medical Office