Sarah Mitchell

The Rt Hon Andrew Stephenson CBE MP 
Minister of State for Health and Secondary Care 

39 Victoria Street 
London 
SW1H 0EU 

020 7210 4850 

10 April 2024 

Darren Stewart OBE 
The Coroner’s Court and Offices 
Beacon House 
Whitehouse Road 
Ipswich  
IP1 5PB  

Dear Mr Stewart, 

Thank you for your Regulation 28 report to prevent future deaths dated  15 January 
about  the  death  of  Sarah  Mitchell.  I  am  replying  as  Minister  with  responsibility  for 
health and secondary care. 

Firstly, I would like to say how saddened I was to read of the circumstances of Miss 
Mitchell’s death and I offer my sincere condolences to their family and loved ones. The 
circumstances  your  report  describes  are  concerning  and  I  am  grateful  to  you  for 
bringing these matters to my attention. Thank you for the additional time provided to 
the department to provide a response. 

The  report  raises  concerns  over  a  lack  of  process  in  place  whereby  accident  and 
emergency  (A&E)  staff  could  access  Ms.  Mitchell’s  medical  records  detailing  the 
medication she was receiving and the rationale behind the dispensing regime in place.  

In preparing this response, Departmental officials have made enquiries with NHS 
England. As I understand, the James Paget University Hospitals NHS Trust (the 
Trust) has provided a response which gives an update on the investigative action 
undertaken and assurance around the Trust’s prescribing policy. I trust their 
response addresses your specific concern around access to medical records for 
A&E staff.  

 in his capacity as Medical 

Following this, I am aware that 
Director of NHS England too has provided a response. NHS England has 
provisioned a programme of work to transition records from the existing system to 
the new National Care Records Service (NCRS) service, which I note, by design will 
remove a large amount of the reported barriers to adoption within many care 
settings. NHS England is operationally responsible for delivering health services 
across the country and will carefully consider further responses provided by the 
Trust. I hope that as an executive non-departmental public body, sponsored by the 
Department of Health and Social Care, the response provided by NHS England has 
addressed your concern. 

1 

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 More broadly on prescribing, I refer you to the professional standards guidance from 
the General Medical Council which highlights that some categories of medicine may 
pose particular risks of serious harm or may be associated with overuse, misuse or 
addiction:  Controlled  drugs  and  other  medicines  where  additional  safeguards  are 
needed  -  professional  standards  -  GMC  (gmc-uk.org).  When  prescribing,  clinicians 
should follow relevant clinical  guidance,  such  as  drug  safety  updates  on the  risk  of 
dependence and addiction associated with opioids. The National Institute for Health 
and  Care  Excellence  has  also  issued  relevant  guidance  on,  “Prescribing  of  drugs 
associated  with  dependence  and  withdrawal  symptoms”:  Overview  |  Medicines 
associated with dependence or withdrawal symptoms: safe prescribing and withdrawal 
management for adults | Guidance | NICE.  

I hope this response is helpful and reassures you that concerns raised in your report 
have been taken very seriously. Thank you for bringing these concerns to my attention.  

Yours sincerely, 

Rt. Hon Andrew Stephenson CBE MP 
Minister of State Health and Secondary Care

r.!1:bj 

James  Paget 
University Hospitals 
NHS  Foundation Trust 

Lowestoft Road 
Gorleston 
Great Yarmouth 
Norfolk
NR31  6LA

25th  January 2024 

Mr Darren Stewart,  OBE 
HM  Area Coroner for Suffolk 
Suffolk Coroner's Court 
Beacon  House 
White House Road 
IPSWICH 
Suffolk,  IP1  4PB 

Dear Mr Stewart 

RE:  Regulation 28 - Report to Prevent Future Deaths 

I am  writing  to  acknowledge  receipt of the  Regulation  28 - Report to  Prevent  Future 
Deaths,  issued  to  the  James  Paget  University  Hospital  NHS  Foundation  Trust 
(JPUH)  following  the  inquest  into  the  death  of  Ms  Sarah  Julie  Mitchell,  which  was 
heard  and  closed  on  27th  November  2023,  and  received  via  our  Legal  Services 
Provider on  9th  January 2024. 

I note your concerns as follows: 

During  the  course  of the  investigation  my inquiries  revealed  matters  giving  rise  to 
concern.  In  my opinion  there  is  a risk that future  deaths could occur unless action is 
taken.  In the circumstances it is my statutory duty to report to you. 

The  MATTERS OF CONCERN are as follows: 
(brief summary of matters of concern) 

The  provision  to  Ms.  MITCHELL  of 28  days' worth  of prescribed medication  in  Jess 
than a 48-hour period (14 days' worth of medication dispensed on each occasion she 
was  discharged hospital on  the  3rd and 4th  of August 2022).  This  occurred at a time 
when,  due  to  concerns  about  Ms.  MITCHELL  hoarding  medication  and  taking  an 
overdose,  she  was  receiving  weekly medication prescriptions from  her GP to  control 
this risk. 

The  evidence heard at Inquest indicated that there was no process in place whereby 
accident  and  emergency  staff  could  access  Ms.  MITCHELL's  medical  records 
detailing  the  medication  she  was  receiving  and the  rationale  behind the  dispensing 
regime in place. 

I note that,  unfortunately,  the  JPUH  was  not  informed  or involved  in  the  inquest and 
we  were, 
therefore,  unable  to  provide  clarification  regarding  these  concerns. 
However,  upon  receipt  of the  Regulation  28,  an  investigation  into  these  matters  of 
concern was commenced. 

 
 
 
 Investigation Outcome 

Provision of Prescribed  Medication 
I have received  assurance from the Trust's Chief Pharmacist that the only medication 
which  Ms  Mitchell  was  given  upon  her first  discharge,  on  3rd  August  2022,  was  one 
  capsules,  equating to  a 10 day supply.  This is  evidenced 
box of 
in the Trust's dispensing record for this patient as  illustrated  below: 

  Fluoxetine 

The  medicines  detailed  on  the  a-Discharge  Summary  represent  the  medicines  the 
patient  was  prescribed  prior  to  admission,  with  any  changes  made  in  hospital,  in 
addition to any new medication  started during their inpatient stay.  This  information  is 
entered  onto the Trust's Electronic Prescribing  and  Medicines Administration (EPMA) 
system  by  the  prescriber  at  the  point  of  discharge.  Information  on  pre-admission 
medicines  is  entered  by the  clerking  doctor,  when  a decision  to  admit  is  made,  and 
obtained  through  a variety of means,  including  directly from  the  patient,  by reviewing 
the patient's Summary Care Review (SCR) and  by reviewing  SystmOne. 

Summary Care  Record  (SCR)  is  a national  database that holds electronic records of 
important patient information  such  as  current medication,  allergies and  details of any 
previous  adverse  reactions  to  medicines,  created  from  the  GP  medical  records. 
It 
can  be  seen  and  used  by  authorised  staff  in  other  areas  of  the  health  and  care 
system involved in the  patient's direct care. 

SystmOne is  a clinical  computer system  used  by GP  practices which  record  patients' 
information  securely.  This  information  can  then  be  shared  with  other  clinicians  at 
other  organisations  directly,  or  via 
the  Emergency 
Department  (ED)  staff to  review  the  patient's  GP  records,  including  medication  and 
prescriptions. 

the  SCR.  This  permits 

The Trust's EPMA system requires a duration to be added for all  prescriptions,  as  per 
the  legal  requirements  for  prescriptions.  This  is  currently  defaulted  to  14  days' 
supply  for discharge  prescriptions,  to  enable  sufficient  time  for  GPs  to  update  their 
records  in  order to  provide ongoing  supplies.  The actual supply given can  range from 
7 - 28  days,  depending on  what the patient brought in  with  them,  what supplies they 
already have at  home  and  what  has  been  supplied  during  their inpatient stay.  There 
is  no  straightforward  way  to  get  the  actual  quantity  supplied  to  match  the  14  days 
referred to in the e-Discharge Summary in the current system. 

 In  summary, thee-Discharge Summary contains a list of medication which the patient 
is  taking  on  discharge,  with  additional  information  specific  to  medicines  that  have 
been  stopped,  started  or amended  during  their inpatient stay.  This  list of medication 
therefore,  does not necessarily relate to what was supplied  by the JPUH. 

Next Steps 
You  may be  aware that the  Norfolk and  Waveney Acute  Hospital Collaborative are in 
the  process  of  procuring  an  Electronic  Patient  Record  system  for  use  across  the 
three acute Trusts.  This will  remove the  need for separate systems,  including  EPMA 
and  e-Discharge and will  eliminate the issues of data transfer between systems. 

It is  anticipated  that the  new EPR system  will  go  live  in  2026.  More  information  can 
be found  by accessing the following  link: better joined up care - EPR - (nwepr.co.uk) 

ED Staff Access to  Medical  Records Process 

,  Assistant  Medical  Director for  the  Division  of Medicine,  Diagnostics  and 
Clinical  Support Services  has confirmed  that staff within  our  ED  have  access to  both 
the Summary Care Record and SystmOne. 

It is  clear that one,  or both  of these  systems were  accessed  on  this occasion,  as  Ms 
Mitchell's  medication was  included  in  the  e-Discharge Summary.  It  is  also  noted  on 
thee-Discharge  Summary,  within  the  Primary Care  Action,  to  'please  only  prescribe 
weekly prescriptions'. 

We  would  always  welcome  opportunities to  be  involved  in  any inquests  in  the future 
and  I trust  that this  adequately  addresses  the  concerns  raised  in  the  Regulation  28 
Report.  However,  should  you  require  any further  clarification  regarding  this,  or any 
other case,  please do not hesitate to contact the Trust. 

Yours sincerely 

Chief Executive 

Enc

Darren Stewart OBE 
Suffolk Coroner’s Court and Offices 
Beacon House 
Whitehoue Road 
Ipswitch  
IP1 5PB 

Dear Coroner, 

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

4 March 2024  

Re: Regulation 28 Report to Prevent Future Deaths – Sarah Mitchell who died on 
22 September 2022.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  8 
January  2024  concerning  the  death  of  Sarah  Mitchell  on  22  September  2022.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Sarah’s family and loved ones. NHS England are 
keen to assure the family and the coroner that the concerns raised about Sarah’s care 
have been listened to and reflected upon.  

In your Report you raised the concern that Accident & Emergency Department staff 
could not access Sarah’s medical records detailing the medication she was already 
receiving and the rationale for her dispensing regime. Sarah was prescribed 28 days’ 
worth of medication within a 48-hour period, at a time where there were concerns that 
she was hoarding medication and despite her history of overdose events.  

Healthcare  organisations  use  a  combination  of  locally  /  regionally  provided  and 
nationally provided information sharing systems to support patient care. A contribution 
from the Shared Care Records programme would be helpful in this case to understand 
what information is provided in the area where the deceased received care through 
any local Shared Care Record or other local sharing agreements.  You may wish to 
refer to Norfolk and Waveney Integrated Care Board (ICB) on this matter as ICBs are 
responsible  for  the  delivery  of  Shared  Care  Records.  This  response  focuses  on 
nationally provided services. 

NHS  England  monitor  the  accesses  made by  organisations  to  the  services  that  we 
support,  including  the  Summary  Care  Record  application  (SCRa)  and  the  National 
Care  Records  Service  (NCRS).  We  publish  some  of  this  information  here: 
https://digital.nhs.uk/data-and-information/data-tools-and-services/tools-for-
accessing-data/deployment-and-utilisation-hub/summary-care-records-deployment-
and-utilisation. 

In  this  case  specifically,  our  dashboards  indicate  that  healthcare  professionals  at 
James Paget University Hospitals NHS Foundation Trust (“the Trust”) have been using 
the Summary Care Record application and the National Care Records Service to view 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 Summary  Care  Records  (among  other  information  e.g.  Demographic  Information, 
Child  Protection  -  Information  Sharing  system,  Covid  Vaccination  information,  etc). 
Accident & Emergency (A&E) staff should be among the staff groups who have access 
to these records at the Trust.  

For background, it is worth mentioning that, in the past, the Summary Care Record 
application (SCRa) was the main method to access SCRs for the existing NHS user 
base. However, NHS England have been involved in a programme of work to transfer 
SCR users from the legacy SCRa service to the new National Care Records Service 
(NCRS) service. This work was accelerated during 2023 and is projected to conclude 
during  Q2  2024.  NCRS  is  the  successor  to  SCRa  and  by  design  removes  a  large 
amount of the reported barriers to adoption within many care settings. The National 
Care Records Service (NCRS) provides a quick, secure way to access national patient 
information to improve clinical decision making and healthcare outcomes, it is free to 
use and includes additional features and services beyond the legacy SCRa product. 
Further 
here: 
NCRS 
https://digital.nhs.uk/services/national-care-records-service. 

information 

found 

can 

be 

on 

SCRa and NCRS both provide access to a patient’s Summary Care Record (unless 
the patient has opted out). The Summary Care Record (SCR) is a national database 
that  holds  electronic  records  of  important  patient  information  such  as  current 
medications, allergies and details of any previous bad reactions to medicines, created 
from GP medical records. It can be seen and used by authorised staff in other areas 
of the health and care system involved in the patient's direct care. Patients are asked 
for  their  permission  to  view  before  this  information  can  be  accessed.  Further 
information about SCR is available here: https://digital.nhs.uk/services/summary-care-
records-scr. 

With  regards  to  current  repeat  medications  in  the  SCR  specifically,  the  information 
includes  details  of  all  current  repeat  medications  including  the  medication  item 
(including  drug  name,  dosage,  and  formulation),  dosage  instructions  (e.g.  take  one 
daily), quantity prescribed and last issue date. Principally, this provides a list of those 
medications  prescribed  by  the  patient’s  GP  Practice  (but  it  is  possible  to  include 
information about those medications which have been prescribed elsewhere, though 
this functionality is often not used for a variety of reasons). Thus, in this case, clinicians 
at  James  Paget  University  Hospitals  NHS  Foundation  Trust  are  likely  to  have  had 
access to information about the Morphine, Promethazine, Gabapentin and Fluoxetine 
prescribed to the patient from their registered GP Practice.  

Provision  of  medication  in  quantities  of  less  than  a  month’s  supply  usually  suggest 
attempts  are  being  made  in  General  Practice  to  control  a  patient’s  access  to 
medication (although this approach might also on some occasions be used for older 
patients who are receiving medications in monitored dosage systems). 

In addition, summary details about the overdose events in this patient’s clinical history 
would  likely  be  captured  within  a  patient’s  GP  Summary,  and  as  a  result  would  be 

 
 
 
 
 
 likely to be present in this patient’s Summary Care Record with Additional Information. 
Further 
found  here: 
https://digital.nhs.uk/services/summary-care-records-scr/additional-information-in-
scr. Currently, 89% of patients have an SCR with Additional Information. 

information  about  SCR  Additional 

Information  can  be 

It is noted in the Regulation 28 letter that this patient suffered from chronic back pain 
for  a  period  of  over  15  years.  As  a result,  this  patient  may  have  had  some  form  of 
healthcare  management  plan e.g.  emergency healthcare plan,  treatment  escalation 
plan, etc. Details of a healthcare management plan can be shared using a local Shared 
Care  Record  or  summary  details  of  a  healthcare  management  plan  can  be  shared 
using  the  Summary  Care  Record.  SCR  also  contains  provision  for  inclusion  of 
information  relating  to  a  ‘Special  Patient  Note’  where  this  has  been  coded  into  the 
patient’s GP record and the patient has an SCR with Additional Information. Clinical 
information  is  best  shared  when  these  ways  of  working  have  been  agreed  up  front 
across the local healthcare economy.  

There is also clear guidance from the General Medical Council (GMC) on prescribing 
responsibilities for healthcare professionals. This includes:  

• 

•  Consideration  of  whether  a  prescriber  has  the  ‘sufficient  information  to 
prescribe safely, for example if you have access to patient’s medical records 
and can verify relevant information’. 
If  not  a  patient’s  regular  prescriber,  prescribers  should  seek  the  patient’s 
consent to contact their GP for further information.  
If  a  patient  objects  to  information  being  shared,  prescribers  must  have 
justification for prescribing without that information.  

• 

NHS  England  would  refer  you  to  James  Paget  University  Hospitals  NHS  Trust  for 
further  information  on  Sarah’s  care  and  your  concerns,  including  their  prescribing 
policies  and  we  note  that  you  have  also  addressed  your  Report  to  them.  We 
understand  that  the  Trust  has  contacted  the  coroner  to  clarify  some  of  the  issues 
referenced within your Report. We have been asked to be sighted on their response 
and will consider this carefully once we are in receipt.  

I would also like to provide further assurances on national NHS England 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 preventable deaths are shared across the NHS at both 
a national and regional level and helps us 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

From: 

To: 

Subject: 
22/09/2022 

 (ROSEDALE SURGERY) 

RE: Prevention of Future Death Report following Inquest of Sarah Julie Mitchell DoD 

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Dear 

, 

In our practice we have yesterday discussed the Prevention of Future Death Report regarding Sarah 
Mitchell in a Clinical Governance meeting. Present in the meeting were myself and 8 other doctors as 
well as 3 of our Health Care Practitioners. 

Two decisions were made: 

1.  The hospital does not easily have access to our clinical system, but they do have access to the 

Summary Care Records, which gives information about diagnosis and medication. 

From now on when a diagnosis of an overdose gets recorded we will add a sentence to give no more 
controlled medication than is needed for 48 hours, so they can contact the surgery again for a further 
supply after. This should be visible on the summary care record that the hospital is looking at. 

2. 

If a patient is admitted with more than 1 overdose within a 3 month period we will change 
their prescription to daily until they have not to overuse or overdose on their medication. 

We hope that with these two new ways of working in place we might be able to bring down the 
chance of accidental death due to an overdose as seems to have happened in Sarah’s case. 

Kind regards, 

1