William Green

Mr Heath Westerman 
HM Assistant Coroner  
Shropshire, Telford and Wrekin  
HM Coroner’s Service 
Guildhall  
Frankwell Quay  
Shrewsbury  
Shropshire 
SY3 8HB 

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

14 April 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – William Stephen Green 
who died on 9 July 2023.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  28 
February  2025  concerning  the  death  of  William  Stephen  Green  on  9  July  2023.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to William’s family and loved ones. NHS England are 
keen to assure the family and the Coroner that the concerns raised about William’s 
care have been listened to and reflected upon.   

Your Report raises the concern that there is no written record explaining or counselling 
patients on the side-effects, and what to do if side-effects are experienced, when a 
patient at The Royal Shrewsbury Hospital is initiated on a new prescribed drug during 
an admission. Your Report also raises that there is no provision in place for patients 
who lack capacity to understand an explanation of the side-effects of prescribed drugs, 
even when this may be offered. In William’s case, he was prescribed an anti-epileptic 
and seizure drug called Lamotrigine between 5 June 2023 and 8 July 2023. 

My  response  to  the  Coroner  has  been  aided  by  engagement  with  NHS  England’s 
National  Clinical  Director 
two  experienced  Clinical 
for  Prescribing  and 
Pharmacologists.  

When  administering  a  new  prescribed  drug  to  patients,  there  should  be  shared 
decision-making and potential risks or complications relevant to the patient should be 
verbally discussed with them, even if very rare. The counselling of patients on their 
medications,  including  documenting  a  record  of  these  discussions  (or  a  lack  of 
capacity  to  engage  with  such  discussion)  is  a  matter  of  professional  duty  and  is 
described by both professional and organisational regulatory bodies.  

It  is  not  standard  practice  in  hospitals  to  document  or  record  if  a  patient  has  been 
counselled  about  the  risk  of  medicines,  apart  from  in  certain  circumstances  where 
consent  is  required  (e.g.,  completing  an  Acknowledgement  of  Risk  form  for  the 
prescription of isotretinoin) or to provide written information on the risk. 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
 
  
 However,  NHS  England  will  take  your  concern  about  counselling,  and  keeping  a 
written record of such counselling, to an appropriate forum for further discussion and 
consideration of any actions we need to take.  

It should also be noted that, on discharge from hospital, patients will be provided with 
the ‘original pack’ medication, and these will contain the Patient Information Leaflet 
(PIL)  which  outlines  the  risks  and  side-effects.  In  the  case  of  Lamotrigine,  the  PIL 
states:  

‘A small number of people taking Lamotrigine get an allergic reaction or potentially life-
threatening skin reaction, which may develop into more serious problems if they are 
not  treated.  These  can  include  Stevens-Johnson  syndrome  (SJS),  toxic  epidermal 
necrolysis  (TEN)  and  Drug  Reaction  with  Eosinophilia  and  Systemic  Symptoms 
(DRESS).  You  need  to  know  the  symptoms  to  look  out  for  while  you  are  taking 
Lamotrigine  Tablets.  This  risk  may  be  associated  with  a  variant  in  genes  in  people 
from Asian origin (mainly Han Chinese and Thai). If you are of such origin and have 
been tested previously carrying this genetic variant (HLA-B* 1502), discuss this with 
your doctor before taking Lamotrigine Tablets.’ 

Your Report does not mention whether William was given the original pack medication 
on discharge from hospital. 

Regarding the capacity of patients, there is clear NHS guidance on how to proceed 
with treatment when someone may lack capacity. There is also legislation (The Mental 
Capacity  Act  2005),  which  provides  a  framework  for  decision-making  on  behalf  of 
people who lack capacity. We would expect Trusts to have their own local policies on 
the administration of new medications, and most Trusts’ Medicine Policies will contain 
guidance on  counselling  patients.  However,  as  above,  they may not direct  that this 
counselling needs to be recorded in the patient’s notes, as this is not standard practice.  

NHS England has also engaged with NHS Shropshire, Telford and Wrekin Integrated 
Care Board (ICB), the responsible commissioner for services delivered by Shrewsbury 
and  Telford  Hospital  NHS  Trust,  on  the  concerns  raised  in  your  Report.  We  are 
advised  that  the  Trust  have  developed  a  Safety  Improvement  Plan,  with  actions 
including:  

•  A Working Group to review patient counselling and informed consent regarding 

medications being prescribed in hospital  

•  Learning from William’s case to be used to deliver training to junior doctors 
•  A new Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis (severe muco-
cutaneous  reactions  usually  caused  by  certain  medicines)  pathway  to  be 
developed and published within the Trust.  

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 
William, 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

Royal Shrewsbury Hospital 

                                                                                                                                                                     Mytton Oak Road 
                                                                                                                                                                              Shrewsbury 
                                                                                                                                                                                Shropshire 
                                                                                                                                                                                  SY3 8XQ 

Mr Heath Westerman, Assistant Coroner  
HM Coroners Service 
Shirehall 
Abbey Foregate 
Shrewsbury 
Shropshire SY2 6ND 

                                                                                                                                                     Tel: 01743 261000 ext. 2580 

       22nd April 2025 

Dear Mr Westman, 

Thank you for your letter dated 28th February 2025 issued under Regulation 28: Report to 
prevent future deaths, in relation to the risks you identified through the inquest examining the 
death of the late William Stephen Green. 

I write to provide details of the steps that we have taken and plan to address the issues 
highlighted in your letter. 

1.  Once any patient at The Royal Shrewsbury Hospital is initiated on a new prescribed drug 

during an admission, no written record is ever made anywhere by anyone including 
pharmacy; nurses; doctors or consultants explaining or counselling the patient upon the 
possible side-effects or complications as a result of taking a specific prescribed drug; nor 
is there any written record on what to look out for and what to do in such circumstances 
and where they can get assistance. 

2.  No provision seems to be in place to record what should happen when the patient lacks 

capacity to understand such an explanation even when it is offered. 

Record of counselling 
The counselling of a patient in hospital should be undertaken by the medical staff on prescribing 
the medication, by the nursing staff and pharmacy staff in preparation for discharge. All 
professions have a role in drug counselling, our pharmacists are the specialists in medication 
and counselling and have access to additional resources and referral services. 
Pharmacy led counselling/documentation: 

•  The current medication counselling standard operating procedure (SOP) only requests a 
memo is entered into the eScript software (the pharmacy drug management system) if 
there is concern a patient does not fully understand the explanation of the new 
medication. This SOP is being updated to require all counselling episodes to be 
documented. This will be fully implemented by the end of May 2025. 

•  A referral to the community-based support services (see below) will also require 

documented evidence on eScript.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  A new patient medication leaflet has been designed and is being introduced to help 
provide further patient information. This leaflet will signpost patients to the NHS drug 
information website that has patient directed information on many of the drugs 
prescribed, including specific information on high-risk drugs and immediate actions to 
take for serious side-effects. This leaflet will be available by September 2025; it has been 
drafted and is currently being taken through the trust accessibility and governance 
processes. 

o  The community services outlined below will supplement the patient information 

leaflet for those patients where the leaflet is not adequate. 

Nurse led counselling: 

•  The nursing staff have a role in providing information especially around the time of 

discharge. The printed discharge summaries will be adapted with the NHS drug website 
highlighted to aid this counselling process. 

•  When a patient is discharged from a non-inpatient area, the patient information leaflet will 

be available to give to patients as they are counselled. 

Informed consent/counselling when prescribing a new medication: 
Treating clinicians have a duty and responsibility to ensure patients are aware of any material 
risk associated with planned treatment, this includes significant side effects of medication. 

•  All senior doctors have statutory training which include safe prescribing. This case will be 

incorporated into this training as a learning example, highlighting the importance of 
adequate counselling, the importance of documenting the process and reminding them of 
the support available for patients who may not immediately understand. The training is 
delivered by the trust pharmacists. 

Ongoing support and counselling 
Not all patients may be able to fully understand and comprehend the new medications started in 
hospital for a variety of reasons. It is also recognised that some medications are high risk, they 
have potentially serious implications of not complying with the medication or have potentially 
serious complications (anti-epilepsy medication is included in this list). 
Once a patient has been discharged from hospital, there are two Integrated Care System (ICS) 
led services that patients can be referred to for ongoing support and monitoring. The Discharge 
Medication Service (DMS) and the Structured Medication Review (SMR) service. 

The DMS is a service where patients identified in the acute care setting who require additional 
support in relation to their medication management can be referred by the pharmacy team. The 
hospital ward staff, doctors or nurses can highlight patients of concern to pharmacy to trigger a 
referral. The general referral criteria are: Admitted patients only, patients initiated on a high-risk 
medication or patients who have been identified with compliance concerns. The referral is 
directed to the patients nominated community pharmacist who will provide counselling and 
additional support in a less stressful environment. 

 
 
 
 
 
 
 
 
 
 
 The SMR is a service where referral is to the GP or the PCN pharmacist for a full medication 
review. This service is to review patient compliance and provide further information/education 
and counselling. There will also be a review of all the medications to ensure they are 
appropriate and optimised. The pharmacy team at SaTH would initiate a referral to this service. 

Following the death of Mr Green and as a result of the internal investigation, a multi-disciplinary 
working group has been set up to address the concerns raised and ensure appropriate actions 
are developed, implemented and embedded in future care. 

Thank you for bringing your concerns to my attention. I hope that you are assured that I have 
taken them seriously, investigated then appropriately and we are putting in place systems and 
processes to reduce future harm. If I can provide any further information, please do not hesitate 
to contact me at the above address. 

Yours sincerely 

Chief Executive Officer