Lilian Board

Mr Paul Cooper 
HM Assistant Coroner for Lincolnshire 
Gilbert Drive 
Endeavour Park 
Boston 
Lincolnshire 
PE21 7TQ  

Date :   24 November 2023 

Legal Services Department 
Trust Headquarters 
Lincoln County Hospital 
Greetwell Road 
Lincoln 
LN2 5QY 

Dear Mr Cooper 

Inquest touching the death of Lilian Board 

Thank you for providing us with a copy of the Regulation 28 Report to Prevent Future Deaths. This letter 
is the response from United Lincolnshire Hospitals NHS Trust (ULHT).  

Firstly, at the outset, the Trust (and myself personally) would like to express our heartfelt condolences to 
Mrs Board’s family and friends for their loss.  

Response to issues raised by the Report 

Firstly, as a personal point of clarity in case this is relevant for any future reference, at the time of this 
patient’s  admission  to  ULHT  and  her  subsequent  death,  I  was  off  on  extended  sick  leave  receiving 
treatment  for  cancer,  and  my  position  was  covered  by 
  as  interim  Medical  Director  for 
ULHT from September 2022 to September 2023, after which I then returned back into my substantive 
Medical Director role. 

 by Mrs Board’s GP and her discharge 
I note that your concern is around the prescription of 
from hospital on 18 January 2023 where she was also prescribed 
. Mrs Board therefore had 
two  prescriptions  of  the  same  medication  that  she  used  to  end  her  life.  You  asked  if  there  were  any 
checks in place to avoid duplicity of prescriptions between the hospital and GP.  

It  is  important  to  point  out  that  the  policy  of  the  Trust  (Policy  for  Medicines  Management  Supply  of 
Medicines),  in  agreement  with  Lincolnshire  Primary  Care  colleagues  including  the  Primary  Care 
Networks, the Local Medical Committee and the Integrated Care Board, is that we supply patients with 
14  days  supply  of  medication  as  a  default  at the  point  of  discharge,  This  is  not  unusual,  as  almost  all 
acute  provider  Trusts  within  NHS  England  have  similar  policies  to  dispense  medication  supplies  upon 
discharge, with these supply arrangements ranging anywhere between 7-28 days depending on policies 
of  the  specific  NHS  Trusts.    A  degree  of  duplicity  is  accepted  in  this  regard,  as  the  vast  majority  of 
patients  discharged  with  a  component  of  overlapping  medication  to  ensure  non-interruption  of  supply 
will simply continue one lot of prescribed medication until this has been completed then switch over to 
the other medication prescription, and patients are counselled about doing this on a case-by-case basis.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 With regard to this particular case, I can confirm that a box of 

 was dispensed (

) in accordance with that policy. For further clarification, Trust staff have access to the summary 
care record, however pharmacy staff will check the validity of the prescription from the dispensary, but 
they do not perform medicines reconciliation from the dispensary. The nursing staff in conjunction with 
pharmacy staff (when appropriate) will however ask the patient what medication they are already on, on 
admission  and  for  example  if  they  are  running  out  of  any  particular  medication.  Nursing  staff  will  then 
check medication at the point of discharge to ensure that patient has their own supplies (or not) and that 
the drugs are as prescribed on the discharge letter, and how to deal with overlapping supplies. 

The  reason  for  why  such  components  of  the  relevant  policies  are  required  is  that  we  have  an 
overarching duty of care to ensure that patients do not come to harm by having an interrupted regime of 
treatment  in  the  intervening  period  of  time  between  being  discharged  from  our  care  and  then  seeing 
their  GP  for  an  amended  prescription,  which  can  often  practically  take  1-2  weeks  (and  in  some 
circumstances, even longer than 2 weeks). Significant harm can occur in circumstances where drugs for 
e.g.  heart  disease  /  stroke  /  epilepsy  /  depression  are  interrupted  in  this  fashion  even  for  only  a  few 
days, which is well recognised.  

We therefore do have to balance ensuring patients are discharged home with a sufficient supply against 
the  unusual  circumstances  of  this  particular  case,  where  I  gather  the  patient  may  have  deliberately 
misled  to  circumvent  processes  in  both  primary  and  secondary  care.  Regarding  that  balance,  it  is 
considered  that  many  more  patients  could  (and  would)  be  harmed  if  they  are  discharged  without  a 
supply of medication and then are entirely reliant on making timely arrangements (which is often beyond 
their control) to seek a supply of dispensed medication via their General Practitioner. GP representative 
bodies  themselves  are  very  clear  both  locally  and  nationally  that  secondary  care  have  the  onus  and 
responsibility  to  ensure  that  patients  are  discharged  from  hospital  with  medications  on  that  basis  to 
avoid inadvertent cessation. Having discussed this case with our Lincolnshire system Medical Director 
colleagues  in  the  Primary  Care  Local  Medical  Committee  and the  Integrated  Care  Board, they  concur 
with  that  consensus  and  maintain  the  opinion  that  the  current  Trust  policy  and  arrangement  remain 
appropriate. 

 tablets, so 
I note that in Mrs Board’s case, it is estimated that she took approximately 
even if ULHT had not discharged her with a further 14 day supply, that estimate implies that she would 
have still had a minimum of 
 tablets in her possession not dispensed by our Trust, which 
would in itself have been a likely fatal dose in overdose. 

We  hope  that  this  response  has  addressed  the  concerns  you  have  outlined.  However,  please  let  me 
know  if you  have  any  further  concerns  or  require  any further  clarifications  around the  nuances of this, 
and I will of course address these accordingly. In addition to the usual communication channels, I can 
be  contacted  via  telephone  /  Teams  etc  if  you  feel  that  might  be  more  helpful  depending  on  what  is 
required in that circumstance.  

Yours sincerely 

Medical Director