Alexandra Roberts

Ms Charlotte Keighley 
HM Assistant Coroner  
Coroner area of Cheshire 
The West Annexe 
Town Hall 
Sankey Street 
Warrington  
Cheshire 
WA1 1UH  

Dear Coroner, 

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

24 February 2025 

Re: Regulation 28 Report to Prevent Future Deaths – Alexandra Bronte 
Roberts who died on 14 May 2023  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  2 
January 2025 concerning the death of Alexandra (‘Alex’) Bronte Roberts on 14 May 
2023. In advance of responding to the specific concerns raised in your Report, I would 
like to express my deep condolences to Alex’s family and loved ones. NHS England 
are keen to assure the family and the Coroner that the concerns raised about Alex’s 
care have been listened to and reflected upon.   

Your Report raised concerns over the minimum amount (300 units) of insulin available 
to be prescribed at the time of Alex’s death and the risk this poses to patients at risk 
of taking an overdose.  

NHS  England’s  National  Clinical  Directors  for  Diabetes  and  Prescribing  have 
considered your Report and have input into this response.  

As  your  Report  notes,  the  smallest  quantity  of  insulin  within  a  single  pen  device  is 
currently 300 units of insulin. You may wish to refer to the Medicines and Healthcare 
products  Regulatory  Agency  (MHRA)  as  the  UK’s  regulator  of  medicines  regarding 
your concerns, as they would be the more appropriate organisation to respond on the 
insulin doses currently available to patients.  

Any risks associated with the prescription of insulin must be weighed against the risk 
of a person with Type 1 diabetes running out of their insulin supply, or being issued 
with less than required, as this can result in the onset of diabetic ketoacidosis (DKA), 
an acute hyperglycaemic emergency, that can potentially be life-threatening. DKA can 
also be precipitated when insulin is missed or withheld, whatever the mode of insulin 
delivery.  

Insulin can be delivered to people in two ways, either via self-administration with an 
insulin pen, or with an automated insulin pump, a small electronic device that releases 
the regular insulin the patient’s body needs throughout the day and night. In general, 
and  in  line  with  the  National  Institute  for  Health  and  Care  Excellence  (NICE) 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 guidelines, the NHS only prescribes insulin pumps to adults with Type 1 diabetes who 
cannot get to their target HbA1C (average blood glucose levels for the last two or three 
months)  without  having  severe  hypoglycaemia  (low  blood  sugar  level)  or  whose 
HbA1c remains high despite carefully trying to manage their diabetes.  

Because  of  the  risk  of  DKA,  it  is  a  general  rule  of  thumb  that  people  with  Type  1 
diabetes should always have access to an insulin pen, even where an insulin pump is 
being used, as the insulin pen is an essential back-up in the case of pump failure.  

Insulin therapy should however be individualised, according to the specific needs of 
the person with diabetes. An individualised insulin regimen takes account of many 
factors, including individual preference, the time action profile required to best fit the 
individual’s glucose profile, lifestyle, activity and various other factors, the amount or 
dose of insulin required, the device required for administration, as well as several 
additional personal and medical factors. 

There are  some  insulin  pens available  that do allow  for  half  unit  dosing.  These  are 
more  commonly  used  in  paediatric  care,  as  they  allow  for  smaller  incremental 
adjustments. However, the total amount of insulin available within the prescription is 
still 300 units.  

Integrated  Care  Board  (ICB), 

My regional colleagues for governance and assurance in the North West have also 
the 
engaged  with  Cheshire  and  Merseyside 
commissioner  of  services  provided  by  Cheshire  and  Wirral  Partnership  NHS 
Foundation Trust regarding the concerns raised in your Report. We are advised that 
the  Head  of  Patient  Safety  and  Quality  -  Medicines  Optimisation  at  Cheshire  and 
Merseyside  ICB  has  contacted  the  ICB’s  Heads  of  Medicines  Optimisation  for 
Cheshire and the Safety Pharmacist to highlight the PFD Report and the Coroner’s 
concerns.  Your  Report  will  also  be  included  for  discussion  by  the  Cheshire  and 
Merseyside Patient Safety Community of Practice. The purpose of the Community of 
Practice  is  to  provide  opportunities  to  build  on  the  work  carried  out  around  patient 
safety and to ensure a learning focused community.  

Further  discussion  has  also  taken  place  between  Cheshire  and  Merseyside  ICB’s 
Head  of  Patient  Safety  and  Quality  -  Medicines  Optimisation,  the  Medicines 
Optimisation  Pharmacist,  Head  of  Medicines  Management  and  the  Head  of  Quality 
and  Safety  within  the  Cheshire  Place  Team.  In  relation  to  the  Coroner’s  concerns, 
NHS England is advised that the following actions will be undertaken: 

•  There  will  be  a  recommendation  to  ensure  that  when  the  annual  medication 
review is undertaken, consideration is given to the patient’s mental health and 
wellbeing if high risk medicines are being prescribed (insulin being one of those 
following this case). 

•  There will be a review of the prescription quantities to ensure that there is no 
over-supply,  to  reduce  the  risk  of  accumulation  (stock  piling)  of  high-risk 
medicines. 

•  The  team  plan  to  discuss  this  case  with  the  GP  concerned  to  establish  any 
learning as a result of this case, and any useful information will be shared. 

 
 
 
 It  would not be appropriate  for  NHS  England  to provide further  comment or  clinical 
opinion on Alex’s case, based on the organisation’s remit and the information provided 
in your Report.  

I  would  also  like  to  provide  further  assurances  on  the  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 events, such as the sad death of Alex, 
are shared across the NHS at both a national and regional level and helps us to 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