Jason Bayley

Your ref: Mr Jason Bayley 

13 December 2023 

Coroner's Court 
Steelhouse Lane 
Birmingham 
B4 6BJ 

CEO 

For  the  attention  of  Ms  Vanessa  McKinley,  Assistant  Coroner  for  Birmingham  and 
Solihull 

Dear Madam, 

Report issued under Regulation 28 of the Coroners (Investigations) Regulations 2013 
to St Andrew’s Healthcare  

1 

Introduction 

1.1 

1.2 

1.3 

I write in response to the above matter and your report dated 17 October 2023.  I have 
considered  your  report,  spoken  with  colleagues  and  directed  further  action.    For  the 
purposes of this response I will refer to St Andrew's as "the Charity". 

I would like to reassure you that the Charity takes the issue of the accuracy of its clinical 
records extremely seriously and ensures that it is setup to allow its clinical teams access 
to the information they need to care for the people in the Charity’s care.  A summary of 
the structure of the Charity’s the Electronic Patient Record (EPR) is set out in this letter 
to provide you with some additional context. 

I  think  it  is  also  worth  stressing  that  the  evidence  you  heard  at  the  inquest  –  from 
witnesses at the Charity and Queen Elizabeth Hospital – is that Mr Bayley received all 
of the dosages for the two other laxatives he was prescribed and the missed dosages 
of lactulose over a period of 4 weeks did not more than minimally or trivially contribute 
to his death.  The witnesses you heard from the Queen Elizabeth Hospital outlined that 
Mr Bayley’s issue with constipation was a chronic problem that had probably developed 
over  a  number  of  years  during  which  time  Mr  Bayley’s  physical  health  had  been 
monitored  appropriately  and  included  a  high  number  of  referrals  to  specialists  at  the 
Queen Elizabeth Hospital. 

2 

Explanation of the EPR 

2.1  The Charity’s EPR consists of three core systems: 

1. 

Rio:  

is  an  electronic  patient  records  system  that  is  designed  to  hold 
information about a person’s mental healthcare.  It is not designed to 
hold information about the prescribing and administration of medicines 
without  an  additional  module  or  system  being  used.    Rio  is  also  not 
designed to hold information about physical healthcare. 

Registered Office St Andrew’s Healthcare, Billing Road, Northampton NN1 5DG 

Telephone 01604 616000    Website www.stah.org 

Registered Charity Number 1104951 Company Number 5176998 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 2. 

EMIS: 

All  St  Andrew’s  ward-based  staff,  including  nursing  colleagues,  have 
access to the Rio system and receive training on how to use Rio during 
their induction.  There is no need for ongoing training on Rio usage as 
colleagues develop competence by using it during every shift. 

is  the  system  used  to  document  physical  healthcare.    This  system  is 
used  to  document  physical  healthcare  investigations,  contacts  and 
results.    Key  information  from  this  system  is  then  automatically 
transferred into Rio.  The EMIS record is akin to a primary healthcare 
record created by a GP surgery, so the structure of the health record is 
no different to a person living in the community or a psychiatric hospital 
that  does  not  have  the  benefit  of  an  internal  physical  healthcare 
resource and has its patients registered at a local GP surgery.  

This system is mainly used by member of the physical healthcare team 
and doctors. 

3. 

ePMA:  

is the system used for the administration and prescription of medication.  
This is the system that prescribers and administrators of medication will 
use  to  setup  and  administer  a  prescription  of  medication.    It  is  the 
primary  record  that  the  key  personnel,  such  as  doctors,  registered 
nurses  and  pharmacists  will  consult  and  review  when  considering 
issues that relate to a patient’s medication. 

2.2  Rio is the primary system used on a day to day basis by the team on the ward.  Due to 
this reason a patient’s Rio record has a number of links in it that enable the Rio user to 
view information from both EMIS and ePMA.  The reasons for this are twofold insofar as 
some members of the team will not have access to EMIS and/or ePMA and also that it 
means  that  all  of  the  information  is  available  in  one  place,  which  is  beneficial  when 
reviewing a patient. 

2.3  Given the ePMA records are transferred into Rio the correct information is available on 
medication  concordance,  but  there  is  a  risk  that  some  of  the  information  in  the  Rio 
progress notes could be inaccurate due to human error. 

2.4  We have enclosed with this response a series of the screenshots of the Rio system to 
provide a visual explanation of how medication information stored in ePMA is available 
in Rio.  

3 

Investigations Undertaken 

3.1  Having compared the missed doses of lactulose with the inaccurate Rio notes we have 
noted that on every occasion the Rio note was made by a colleague who was different 
to  the  one  who  administered  the  medication.    During  this  period,  where  Mr  Bayley 
missed a dose of lactulose and the Rio note documenting the shift handover was made 
by  the  person  who  administered  his  medication  the  Rio  note  is  accurate.    The  staff 
making  these  notes  vary  in  seniority  from  healthcare  assistants  to  a  deputy  ward 
manager. 

3.2 

It would appear that the reason for the discrepancy between the ePMA record and the 
shift handover Rio note is the author not being aware of what medication a patient did 
and did not accept.  The Charity is going to speak with all the colleagues who did not 
make  accurate  entries  to  establish  the  reason  for  this  and  to  remind  them  of  the 
importance of accurate record keeping in management supervisions.   

 
 
 
 
 
 
 
 
 
 
 4 

Actions Taken 

4.1 

In  order  to  address  the  issue  with  the  inaccuracy  of  the  Rio  notes  that  relate  to 
medication the Charity is undertaking the following actions: 

Action 1: Reminding staff of the importance of good record keeping 
4.2  The Charity has commissioned its Clinical Audit Team to undertake an audit reconciling 
Rio notes that relate to medication with the ePMA records.  This will enable the Charity 
to review the extent of the issue that is the subject of the Regulation 28 report. 

Action 2: Reminding staff of the importance of good record keeping 
4.3  The  Charity  has  a  weekly  clinical  briefing  called  the  Pulse  which  is  received  by  all 
colleagues.  We have included a message on the importance of accurate record keeping 
as well as another on the importance of documenting in Rio if a patient misses a dose 
of medication. 

Action 3: Ensuring CPUMs review EPMA data 
4.4  The Charity senior clinicians have communicated to their medical colleagues that every 
Care Plan Update Meeting/Ward Round should include a review of the last two weeks 
medication  records  on  ePMA.    This  will  ensure  missed  doses  of  medication  will  be 
noticed even if the Rio notes are incorrect.  

Action 4: Investigating a technical solution 
4.5  The  Charity  is  currently  undertaking  a  project  to  consider  if  ePMA  can  automatically 
make a Rio progress note documenting medication administration events.  This would 
negate the need for this information to be included in the shift summary notes. 

4.6 

In  addition,  the  Charity  is  investigating  if  an  ePMA  can  send  a  patient’s  responsible 
clinician an alert if consecutive doses of medication are missed by a patient.  In addition 
to  the  technical  feasibility  of  this  proposed  development,  the  Charity  also  needs  to 
consider the effect of ‘alert fatigue’ in the sense that the effectiveness of such alerts will 
be reduced if key clinicians receive too many alerts as they will start to be ignored. 

5 

Summary 

5.1  Having  considered  your  report,  we  acknowledge  that  there  should  not  have  been  a 
discrepancy  between  Mr  Bayley’s  ePMA  record  and  the  shift  handover  notes 
documented in his Rio progress notes. 

5.2  The Charity will take the actions outlined above in order to improve the accuracy of the 

progress notes. 

5.3  We would also highlight that you may not have been provided with detailed information 
of how the Charity’s EPR systems operate and are reviewed, which would have given 
you a better understanding of how the ePMA is used by clinicians.  The Charity’s position 
is  that  the  prominent  system  for  checking  the  prescribing  and  administration  of 
medication  is  ePMA  which  is  regularly  checked  by  doctors  and  is  used  by  nurses  at 
every instance of medication administration. There are therefore controls in place which 
address the risk of incorrect information about medication administration being entered 
into the progress notes of Rio, which is not the main system for medication management.  

 
 
 
 
 
 
 
 
 
 
 
 
 5.4  Senior  clinicians  in  the  Charity  have  considered  your  concern  that  “accurate 
documentation of whether medication has been taken in the Rio notes is an important 
safeguard against harm and a mechanism to promote appropriate care planning.”  The 
view  of the  Charity’s  senior  clinical  leadership  team  is that  there  is  no reason  for the 
discrepancy  between  the  ePMA  record  and  the  Rio  progress  notes,  but  that  the  Rio 
progress notes documenting medication concordance are a secondary safeguard as the 
primary safeguards are the ePMA records, regular reviews of a patient’s care and the 
Patient Safety Dashboard. It may be that these factors were not clearly explained at the 
inquest touching upon Mr Bayley’s death.  

5.5 

I hope this response goes some way to address the concerns you have highlighted in 
your report. 

Yours faithfully 

Chief Executive Officer