Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0227, written 13 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 May 2025 |
|---|---|
| Reference | 2025-0227 |
| Deceased | Margaret Reeves |
| Coroner | Joanne Andrews |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Alcohol, drug and medication related deaths · Suicide (from 2015) |
| Organisation named | Sussex Partnership NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Sussex Partnership NHS Foundation Trust 2 NHS Sussex 1 CORONER I am Joanne ANDREWS, Area Coroner for the coroner area of West Sussex, Brighton and Hove 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 08 March 2023 I commenced an investigation into the death of Margaret Kagure Pauline REECE aged 39. The investigation concluded at the end of the inquest on 12 May 2025. The conclusion of the inquest was that: Margaret Kagure Pauline Reece died on 7 March 2023 at Shoreham-by-Sea, West Sussex having been found hanging at her home address. , 4 CIRCUMSTANCES OF THE DEATH Margaret Kagure Pauline Reece attended her GP on 13 February 2023 in a state of extreme distress reporting suicidal ideation without intent. Due to her distress her GP prescribed her 2mgs PRN Diazepam in the form of 12 tablets which would last her for 2 days at the maximum dosage. The GP also issued a deferred prescription for collection on 16 February of the same amount. Her GP at that time referred her for a mental health assessment by Sussex Partnership NHS Foundation Trust. The Court heard that it was the GP’s intention that Mrs Reece would be seen by the Mental Health services prior to the end of the Diazepam prescription. On 17 February 2023 Mrs Reece was seen by the Mental Health Team who were concerned about her use of Diazepam due to its risk of dependency and as such decided that she should be weaned from Diazepam and started on an increasing dose of Quetiapine. A GP Medication Letter was handwritten by the Associate Specialist that and sent to the GP which detailed the actions which the Doctor had determined should be taken by the GP to achieve the titration of medication for Mrs Reece. This was not received by the GP surgery and no explanation can be provided as to why this was. This was the only document which detailed the role which the GP was being Regulation 28 – After Inquest Template Updated 15/10//2024 TG asked to perform in relation to the reduction of the Diazepam. A letter was also sent by Sussex Partnership NHS Foundation Trust on the same day to the GP with the outcome of the assessment of Mrs Reece which was received. This detailed that there was a plan for the reduction of Diazepam and introduction of Quetiapine but no information was given as to how this should be done or what was expected of the GP in that process. This letter was received by the GP on 18 February 2023. The GP in their evidence stated that they assumed that Mrs Reece had been given instructions as to how to reduce the Diazepam. Mrs Reece requested further Diazepam from the GP on 21 February. The GP was aware of the letter from Sussex Partnership NHS Foundation Trust and as such gave a limited prescription of 2mgs Diazepam which, if taken at maximum dose, amounted to a further 2 days. Mrs Reece was sent a text by the GP requesting that she make an appointment to check on her titration of Diazepam in 2 weeks’ time. On 28 February 2023 Mrs Reece was seen by Sussex Partnership NHS Foundation Trust and found to be in withdrawal from Diazepam having last taken Diazepam on 24 February when she ran out. She had contacted 111 over that weekend to obtain a prescription but had been unable to do so. She was issued with a prescription for Diazepam by the Psychiatrist that day. This was a prescription for the doses which had been set in the GP Medication Letter of 17 February 2023 to titrate Mrs Reece’s medications. In the course of the evidence, the Court heard that whilst Sussex Partnership NHS Foundation Trust have access to Plexus and thus a limited amount of information from the GP surgeries there is no reciprocal arrangement in place so as to enable GPs to understand the prescriptions which have been issued for their patients or to check that they have instructions on medications which they are or are not supervising for the Mental Health Services. The Court heard that the NHS England project for sharing of information was in progress but in the interim, and no date was given as to when this would be completed, the position remains as it was at the time that Mrs Reece died. 5 CORONER’S CONCERNS 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 that in the absence of information being made available to the GP there is a risk that patients will not receive any medication or receive excessive amounts of medication due to the risk of duplicitous prescribing. Regulation 28 – After Inquest Template Updated 15/10//2024 TG 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by July 08, 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Mrs Reece Northbourne Medical Centre I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 13/05/2025 Joanne ANDREWS Area Coroner for West Sussex, Brighton and Hove Regulation 28 – After Inquest Template Updated 15/10//2024 TG
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Ms Joanne Andrews Area Coroner County Records Office HM Coroners Office Orchard Street Chichester West Sussex PO19 1DD 7 July 2025 Dear Ms Andrews NHS Sussex Sackville House Brooks Close Lewes East Sussex BN7 2FZ Tel: 0800 433 4545 E-mail: Website: www.sussex.ics.nhs.uk I write in response to your Regulation 28 report, dated 13 May 2025, setting out your concerns after hearing evidence at the Inquest in relation to the death of Margaret Reece. I wish to begin by extending my sincere condolences to Margaret Reece’ family and friends. The inquest proceedings must have been an extremely difficult time for them. I address your concern below, following consultation with senior commissioners in the digital, data, analysis and technology team: In the absence of information being available to the GP there is a risk that patients will not receive any medication or will receive excessive amounts of medication due to duplicate prescribing. The usual method of communicating the changes in a patients’ care and in particular changes to their medication with GPs is by sending a letter or email update to the GP’s surgery. This method is standard practice following admissions and outpatient appointments to reflect the changes to a patient’s treatment regime and summarise the care required. In addition, if the patient attends an appointment with a GP, a recent history will usually be taken directly from them. There is no statutory requirement in the Health Act 2022 for Integrated Care Boards to implement shared care records or to ensure particular organisations have access to them. NHS Sussex is in the process of rolling out the shared care record to primary care in this financial year (2025/2026). In the coming years the information NHS providers will be able to access about a patient will be replaced by the national Shared Care Record which NHS England is currently developing. Shared care records are a summary of patient details and interactions with health and care services. A shared care record is not a tool for collating or sharing correspondence between NHS organisations or a communication channel between NHS providers. For patients with unclear, complex or rapidly changing needs, clinicians will continue to need to communicate with one another via other methods to ensure they have a full picture to support their clinical decisions. The different health care services use a number of different systems, and the shared care record allows the information to be drawn together across the different systems. It is a way for the GPs to see patient interactions with the different providers who submit data to the shared care records. However, the version being rolled out by the ICB this year will only show the interactions with health care professionals and will not include access to the letters or other documents. It will be developed to include more detailed information over time but in the early stages will only show that there has been interaction with another NHS service and will not include the details. We are aware that the Sussex Partnership NHS Foundation Trust (SPFT) will be moving over to using Electronic Patient Records later this year which will enable them to share more detailed records with GPs and others health services. Thank you for bringing your concerns to my attention. I hope that we have provided you and Margaret Reece’ family with some assurance that NHS Sussex ICB has is taking steps to address the concerns outlined in your report and that we are continuing to take action to prioritise patient safety. Please do not hesitate to contact me if I can be of any further assistance. Yours sincerely Chief Nursing Officer On behalf of NHS Sussex
3 July 2025
Via Email:
FAO: HM Area Coroner- Ms Joanne Andrews
Dear Ms Andrews,
I am writing to respond to the Regulation 28 report following the inquest into Margaret
Reece's death.
I was sorry to hear about Margaret's sad death, and I would like to offer my condolences to
her family.
I understand that the inquest highlighted concerns that there is no automatic arrangement
in place to enable GPs to have sight of the prescriptions which have been issued by the
Trust, nor are instructions on the use of medications automatically conveyed once changes
are made. Understandably, you are concerned that without such information, there is a risk
that patients will not receive repeat prescriptions for their medication, or they might receive
excessive amounts of medication due to the risk of duplicate prescribing.
I am able to confirm that after a lengthy consultation, procurement and enablement process,
in November 2025 the Trust will be migrating to a new Electronic Patient Record system,
namely SystmOne. This system is widely used by many other NHS providers, including GPs
and has the potential for incorporated prescribing functions. After November, the Trust will
therefore be able to integrate with GP surgery systems and facilitate two-way and real time
sharing of information which should alleviate this risk considerably.
As you will appreciate, this technical mechanism for sharing will remain dependent on
patient consent (or an overriding lawful reason to share without consent) and GP Practices
enabling the system from their end, to ensure they can access the Trust records. I can
assure you that the Trust is actively working to enable sharing and to provide sharing
agreements with our GP colleagues.
In addition, as a part of our broader IT developments we are also working to establish
electronic prescribing which will further enhance the safety of prescribing practices. This is
a more complex part of the programme and the time frame for a complete roll out is not clear
at this stage, however it remains a priority for us. Given the risk concerns you have identified,
Chair:
Chief Executive:
Head office: Sussex Partnership NHS Foundation Trust, Portland House,
44 Richmond Road, Worthing, West Sussex, BN11 1HS
A teaching trust of Brighton
and Sussex Medical School
we anticipate that community electronic prescribing will be adopted as a priority and should
be rolled out at the same time as we adopt SystmOne however.
Thank you for raising this important matter. I hope that the content of this response provides
you and Ms Reece's family with some assurance that this is something that we have
identified as a risk concern and are actively working to resolve. We hope these and other
changes such as our redesign of community services, will improve information sharing
between the Trust and GP practices so as to deliver consistent, quality, partnership care.
If I can be of any further assistance to you, please do not hesitate to contact me.
Yours sincerely
Consultant Psychiatrist
Chief Medical Officer
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