Joshua Burgess

Prevention of Future Deaths Report (Regulation 28): Godfrey Care 
Response. 27th March 2024.  

Coroners Concerns 
Godfrey Care were informed by Mr Burgess’ mother and the Neurology department of Royal Stoke 
University that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld 
between 22-26 July 2022 due to the information not being in writing from the prescriber, however 
the evidence at inquest was that 10ml twice daily was commenced on 26 July 2022 following a call to 
the 111 service.  

Godfrey Care Response 
We intend to review our internal policies and procedures considering the coroners concerns and 
identify where changes need to be made. Below, we respond to the coroner’s areas of concern, 
setting out what we have already done, what we are doing now, and what we intend to do in the 
future.  

Lessons Learned 
On the 1st March 2024, medication communication and lessons learned session completed with all 
deputy managers, managers, and senior leaders of the organisation. Criteria covered and addressed:  

•  Emergency admissions  
•  No labels on medication  
•  Parents stipulating what agreed dosages are. 
•  Specialist prescribers (such as neurologists)  
•  GP prescriptions that differ to specialist prescribers 
•  Triangulation in these circumstances.  
•  Run through the reviewed managers monthly medication audit to ensure expectations are 

clear.  

The session was an opportunity to review the effectiveness of Godfrey Care medication procedures, 
identify what works well and what needs improvement. Key findings and recommendations: 

•  Weekly medication audits; to be conducted by a competent and trained person such as 

team leader, deputy manager or manager of a service.  

•  Verbal medication changes during appointments; written confirmation to be received from 
the clinician making changes to medication, prior to Godfrey Care staff making any changes 
to medication. A new prescription to be ordered and received within 48 hours, 72 hours 
maximum.  

 
 
 
 
 
 
 
 Reviewed Policies and Procedures 
The following actions will be implemented by 1st April 2024.  

1.  Local Medication policy implementation, in addition to the organisations external provider’s 

QCS medication policies and procedures (Quality Compliance Systems).  

1.1 The local policy is clear in relation to receiving and checking in medication delivered from an 
alternative provision, other than a pharmacist, such as a family member or a previous care 
provider. We recognised the need to strengthen our procedure for checking in medication for a 
person transitioning from a family home or another care provider to Godfrey Care, where 
medication is not delivered straight from a pharmacist.  

9.1 “Receiving  and  checking  in  Medication  delivered  from  an  alternative  provision,  such  as 

family member or previous care provider.  

All medication to be checked in, check the medication against the MAR sheet given if supplied and 
document  on  the  back  of the  MAR  the  date,  the  individual  medication  name  and  dosage,  quantity 
received and sign.  

If  the  person  has  moved  in  with  no  MAR sheet,  (see  section  6, transcribing)  medication  prescribed 
(transcribed  from  medication  labels),  dosage,  quantity  received,  to  be  handwritten  on  a  new  MAR 
sheet  with  the  details  of  the  person  clearly  documented  at  the  top,  date  of  birth  and  any  known 
allergies etc. and signed by two medication competent staff.   

If a label has been altered in any way or is illegible or has been removed, the pharmacy responsible for 
dispensing the medication should be contacted and new prescribed medication labels to be requested. 
If there are further issues with the prescription labels, then an appropriate health professional must be 
contacted immediately, and their  advice sought  before the medication is administered. Medication 
prescribed  dosages  must  be  received  in  writing  by  a prescribing  clinician  prior  to  administration  of 
medication (see section 18, remote prescription, or direction to administer). Any medication dosages 
missed, must be reported to an appropriate health professional for their advice, and a safeguarding 
referral made.” 

1.2 The local policy is clear in relation to remote medication prescription or direction to administer 
made by a GP or other clinician. We recognised the importance of triangulation where multiple 
prescribers are involved with a person we support.  

“18. Remote prescription or direction to administer. 

At times medication changes mid cycle may be agreed with a GP or other clinician such as neurologist, 
psychiatrist, or dentist.  

A verbal order to change medication is  not acceptable on its  own. The fax  or email prescription or 
direction to administer must be stapled to the service user’s existing MAR. This should be followed up 
by a new prescription within normally 48 hours (72 hours maximum – bank holidays and weekends). 
In any event, the changes must have been authorised (via text, email, or fax) by a registered prescriber 
before the new dosage is administered.  

 
 
 
 
 
 
 
 
 
 
 
 Triangulation: where it is a clinician’s responsibility to send the update of changes to a GP surgery, to 
enable  them  to  update  the  prescription,  this  should be  followed  up  with  the surgery to  ensure  the 
appropriate changes are made and a new prescription ordered.  

Suitably trained persons should note that remote prescribing cannot be undertaken in a care service 
because they do not have access to a stock of medicines.”  

2  The Weekly Medication Audit and Monthly Managers Medication Audit already include a check 

for legible labels, and have been reviewed to include the following prompt to check:  

“Any prescribed medication changes mid cycle has been agreed with GP or other clinician such as 
neurologist, psychiatrist, or dentist. Written confirmation has been received as evidence to make the 
changes, and a new prescription with new dosage received withing 48 hours, 72 hours maximum?” 

3  The Staff Medication Competency Assessment has been reviewed and now includes the 

following questions. 

“Can the colleague explain the appropriate steps they would take to clarify unclear or illegible 
directions?  

Can the colleague explain the steps they would take if the MAR instructions differed to the 
instructions on the label of the medicine?  

Can the colleague explain the protocol for verbal changes to medication following an appointment?”

Executive Suite 
Trust Headquarters 
Springfield 
City General Site 
Newcastle Road 
Stoke on Trent 
ST4 6QG 

9 April 2024 

STRICTLY PRIVATE & CONFIDENTIAL 
Mr Daniel Howe 
H M Assistant Coroner  
Stoke on Trent and North Staffordshire 

Dear Mr Howe 

Joshua BURGESS  

Further to your letter 13 February 2024, I am pleased to provide a response under paragraph 7 of Schedule 
5  of  the  Coroners  and  Justice  Act  2009  and  Regulations  28  and  29  of  the  coroner’s  (Investigations) 
Regulations 2013, addressing your concerns surrounding the death of Joshua Burgess.  

This  response  is  provided  on  behalf  of  Brooke  Medical  Centre  and  the  University  Hospitals  of  North 
Midlands NHS Trust. 

Recorded Circumstances of the Death 
Joshua Burgess was a 27 year old male who had severe acquired brain injuries, communication difficulties, 
impaired executive functioning and severe learning difficulties. He developed epilepsy from the age of 6 
years and had a diagnosis of Lennox-Gestaut syndrome for which he was under the care of the Department 
of  Neurology  at  Royal  Stoke  University  Hospital.  In  2019  the  Department  of  Neurology  commenced  Mr 
Burgess on 2.5ml twice daily Brivaracetam to control his seizure activity. The dosage was increased to 10ml 
twice a day in 2020 and responsibility for prescribing the medication was transferred to Mr Burgess’ General 
Practitioner at the Brook Medical Centre, Bradeley, Stoke-on-Trent. The reason for the change in prescriber 
was for the sake of convenience as the GP were the prescriber for other medications. 

Although  the  Brook  Medical  Centre  were  responsible  for  prescribing  Brivaracetam  there  were  no 
consultations between the surgery and Mr Burgess or his mother regarding the management of his seizures 
or a review of medication, these continued to be undertaken by the Department of Neurology at the Royal 
Stoke University Hospital. 

In July 2020 the Consultant Neurologist agreed with Mr Burgess’ mother that the dosage of Brivaracetam 
should  be  reduced  by  2ml  every  2  weeks  and  to  be  reviewed  in  4  months.  A  letter  was  sent  from  the 
Department of Neurology at Royal Stoke University Hospital to the Brook Medical Centre advising of this 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
    
 
 
 
 
 
 
 
 
 
 
 
 planned reduction. No amendment to the prescription was requested and no changes were made following 
the letter. The prescription remained as Brivaracetam 10ml twice daily. 

In November 2020 a letter was sent from the Department of Neurology at Royal Stoke University Hospital 
to the Brook Medical Centre advising that the dose of Brivaracetam had been reduced to 3ml twice daily 
but then back up to 5ml twice daily. No amendment to the prescription was requested and no changes were 
made following the letter. 

In January 2021 a letter was sent from the Department of Neurology to the Brook Medical Centre advising 
that the dose of Brivaracetam was at 4ml twice daily and the deceased’s seizures were “relatively stable”. 
No  amendment  to  the  prescription  was  requested  and  no  changes  were  made  following  the  letter.  The 
prescription remained as Brivaracetam 10ml twice daily. 

On 22 July 2022 Mr. Burgess was moved out of his parent’s care by Stoke-on-Trent social services into a 
supportive living placement in Leicestershire run by Godfrey Care. This was undertaken on an emergency 
basis. When Mr. Burgess arrived at the placement it was reported by staff that the medication bottles were 
unlabeled and so could not be given to Mr Burgess until confirmation of the prescription was received in 
writing  by  the  prescriber.  The  evidence  at  inquest  was  that  this  was  a  Care  Quality  Commission 
requirement. 

The deceased did not receive any Brivaracetam between 22 July 2022 and 26 July 2022. 

On 25 July 2022 a “Best Interests Meeting” was undertaken involving Mr Burgess’ mother, Godfrey care 
and social services during which the Mr Burgess’ mother advised that the correct dosage of Brivaracetam 
was 4ml twice daily and not 10ml twice daily. The same information was provided by the Department of 
Neurology  to  Godfrey  Care  however  the  medication  was  not  provided  as  the  information  regarding  the 
correct dose had not been provided by the prescriber. 

On 26 July 2022 the deceased was given Brivaracetam 10ml twice daily. The evidence at inquest was that 
this was likely due to a manager from Godfrey Care being given the prescription details during a call to the 
111 service. 

On 27 July 2022 a letter was sent from the Department of Neurology to the Brook Medical Centre explaining 
that Mr Burgess had been moved to a care organisation on an urgent basis and there was confusion over 
what  medication  he  should  be  taking.  A  request  was  made  to  forward  a  list  of  his  medication  but  also 
included information from his last review within the Department of Neurology that Brivaracetam at 4ml twice 
daily was the appropriate dose.  

On 28 July 2022 the Brook Medical Centre sent a list of prescribed medication to Godfrey Care. As there 
had been no changes to prescription since July 2020 the recorded prescribed dose of Brivaracetam was 
10ml twice daily although the dose that he has been given during the preceding 2 years was 4ml twice daily.  

Mr Burgess continued to receive Brivaracetam at dose of 10ml twice daily until 5 September 2022 when he 
was seen in a clinic at Department of Neurology at Leicester Glenfield Hospital and established that there 
had been a sudden increase in the Brivaracetam dose from 4ml twice daily to 10ml twice daily. The plan 
was for the medication to be reduced to 9ml twice daily and then to continue to reduce by 1ml twice daily 
at weekly intervals until he was back to the “well tolerated” dose of 4ml twice daily.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Prior  to  22  July  2022  whilst  being  given  Brivaracetam  at  4ml  twice  daily  Mr  Burgess  experienced  5-6 
seizures  per  week.  Following  the  cessation  of  medication between  22-26  July  2022  and  the  increase  in 
Brivaracetam to 10ml twice daily he was experiencing about 5 seizures per day and of longer duration.  

The medication was reduced as per the instruction from Department of Neurology at Leicester Glenfield 
Hospital. On 23 September 2022 Mr Burgess was taken back into care of his mother. Although there had 
been a hospital attendance on the 15 November 2022 the seizures had stabilised to a similar frequency as 
before the sudden interruption and increase in medication. 

On 19 November 2022 Mr Burgess was sadly found unresponsive at his home address with death being 
verified by a paramedic. He had passed away after vomiting and aspirating during an epileptic seizure. 

Concerns 
During the course of the inquest, you felt that evidence revealed matters giving rise for concern. In your 
opinion, matters for concern are as follows: 

1.  The Neurology department of the Royal Stoke University Hospital operated a system whereby it did 
not instruct the prescribing GP to amend the prescription of Brivaracetam when changes to dosage 
had been agreed with Mr Burgess’ mother. The evidence from the Consultant Neurologist was that 
an assumption was made that when changes to medication had been discussed and agreed that 
Mr Burgess’ mother would attend the GP surgery to discuss the changes in medication. The same 
witness  gave  evidence  that  it  was  assumed  a  pharmacist  within  the  GP  surgery  would  read  the 
correspondence from the neurology department and make the necessary changes to prescriptions 
without express instructions to do so.  

2.  The  ‘workflow’  within  the  Brook  Medical  Centre  was  such  that  letters  sent  from  the  Neurology 
Department  discussing  changes  in  medication  (albeit  not  containing  a  request  to  amend  the 
prescription) were processed by support staff and not referred to a clinician to consider and so no 
changes were made to the prescription. 

3.  The  letter  of  27  July  2022  from  the  Neurology  Department  to  Brook  Medical  Centre  seeking 
clarification as to the correct dosage of Brivaracetam was processed by support staff and a summary 
medication sent without referral to a clinician. 

4.  Godfrey Care were informed by Mr Burgess’ mother and the Neurology Department of Royal Stoke 
University Hospital that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was 
withheld between 22-26 July 2022 due to the information not being in writing from the prescriber, 
however the evidence at inquest was that 10ml twice daily was commenced on 26 July following a 
call to the 111 service.  

You  reported  this  matter  under  Paragraph  7,  Schedule  5  of  the  Coroners  and  Justice  Act  2009  and 
Regulations 28 and 29 of the coroners (Investigations) Regulations 2013.  

In your opinion, action should be taken to prevent future deaths.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Action Taken 
The University Hospitals of North Midlands NHS Trust has taken the issues highlighted during the inquest 
seriously and indeed, I am grateful that you have raised your concerns. 

We have taken this opportunity to work together with our partners in primary care and have consulted with 
colleagues from the wider the Integrated Care System (ICS). 

1.  The Trust’s outpatient clinic letter standards describe the structure of clinic letters based on standard 
headings. You will recall that 
 (GP) gave evidence at the inquest to the effect that there were 
areas in the acute Trust setting which already provided discharge information which he considered 
to be of a ‘gold standard.’  The Trust is committed to working towards improving compliance with 
these standards.  To support this, we are working towards creation of a standardised template in 
our ‘Medisec’ system (system where letters are created). This will include a section for changes to 
medications and clear actions for those in the primary care setting, for example, instructions for the 
prescribing GP to amend prescriptions. 

2.  We  have  discussed  the  above  process  with  nominated  individuals  from  the  ICS.  Due  to  the 
timeframes that would be required for the creation of standardised template for clinic letters within 
the  ‘Medisec’  system  across  the  Trust,  we  are  reiterating  the  Trust  standards  and 
  has 
agreed, with immediate effect, that all clinic letters received from neurology will be reviewed by a 
GP  at  Brook  Medical  Centre.  This  has  been  implemented  due  to  the  acknowledgement  that 
neurological  conditions  are  often  complex,  and  it  is  more  likely  that  they  will  require  frequent 
medication changes, titration and/or closer monitoring. 

3.  This concern will also be addressed by the interim solution implemented by Brook Medical Centre, 
in that all correspondence from the neurology department will be reviewed and triaged by a GP. 

4.  Whilst this concern is not directly addressed to the acute Trust (UHNM) or Brook medical Centre, it 
has been considered as part of the wider learning following Joshua’s death. Medications for epilepsy 
is considered across the healthcare economy to be ‘critical’. The National Patient Safety Agency 
(2010) defined critical medicines as ‘medicines which can result in patient death or serious harm if 
there  are  delays  in  their  administration’.  Whist  the  Coroner  found  that  the  delay  in  administering 
medications on this occasion did not contribute to Joshua’s death, we believe that further education 
within  the  care  home  setting  is  required.  With  this  in  mind,  we  will  work  together  with  the  local 
authority to ensure that up to date communications are shared across the Stoke on Trent and North 
Staffordshire health and social care economy to reiterate this message. Whilst this has not yet been 
implemented, it will be taken forward by end of May 2024.  

Whilst  some  changes  have  been  implemented  with  immediate  effect,  other  planned  changes  may  take 
longer. However, we are committed to ensuring that correspondence between service providers is provided 
in an accurate and consistent manner.  

We do hope that the above information provides assurance that the Trust and Brook Medical Centre have 
taken  the  concerns  raised  at  the  inquest  seriously  and  that  we  are  working  together  to  ensure  that 
communication of medication changes is clear and unambiguous between partners across the Staffordshire 
and Stoke on Trent health economy.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Should you wish to discuss any aspect of this report further, please do not hesitate to contact us directly. 

Yours sincerely 

CHIEF EXECUTIVE 

BROOK MEDICAL CENTRE 

(electronically approved)