Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0296, written 12 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Jun 2025 |
|---|---|
| Reference | 2025-0296 |
| Deceased | Michael Barry |
| Coroner | Sean Horstead |
| Coroner area | Essex |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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 FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mid and South Essex Integrated Care Board Department of Health and Social Care NHS England & NHS Improvement CORONER I am Sean Horstead, Area Coroner, for the coroner area of Essex 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. INVESTIGATION and INQUEST On 8th September 2023 I commenced an investigation into the death of Michael Paul Barry aged 46 years. The investigation concluded at the end of the inquest on the 30th May 2025. Mr Barry died at Broomfield Hospital, Court Road, Chelmsford, Essex from a confirmed medical cause of death, following Post ‘Ia Pneumonia’ and, under Part II (as having Mortem examination, of contributed to the death but not a direct cause): ‘Excessive use of Codeine’. I provided a Narrative Conclusion confirming that the deceased died, despite optimal medical care following admission to Hospital, from fatal complications of a community acquired pneumonia on a background of excessive use of Codeine medication. Notwithstanding evidence of the deceased’s history of mental health issues and previous suicidal ideation, and an attempt to take his own life by way of overdose some three months prior to his death, the evidence did not disclose to the requisite standard of proof the deceased’s intent at the time of taking excessive codeine medication in the period prior to his last hospitalisation. 1 2 3 4 CIRCUMSTANCES OF THE DEATH 1 The deceased had a long-standing history of mental health problems and illicit drug and alcohol misuse. By the time of his death Mr Barry’s use of illicit drugs had significantly diminished (though he continued to ‘binge drink’ to excess). However, he had developed a long-standing dependency on prescribed opiate based pain-killing medication following significant surgery some years prior to his death. Whilst the evidence did not disclose the source of the codeine taken in excess prior to his death, the evidence positively confirmed that, absent concomitantly raised paracetamol levels, the codeine identified in the toxicological analysis was likely not from the medication prescribed by the deceased’s GP Practice. Accordingly, no direct causative link could be found, to the requisite standard of proof, between the prescribed medication itself and the death and, further, no finding or determination was made that was critical of the GP’s on-going prescribing of the pain-killing medication. However, the lack of specialist support to which the GP could refer the patient was a significant concern. 5 CORONER’S CONCERNS During the inquest the evidence revealed matters giving rise to concern and in my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – Notwithstanding the positive finding that the specific medication prescribed by Mr Barry’s GP had not been the source of the excessive codeine taken prior to admission to hospital, compelling evidence was received at the inquest from a Partner at the GP Practice (with a particular specialism in this area of dependency-forming medications) no specialist commissioned service available for GPs to which they might refer their patients to manage reduction of their intake of prescribed dependency-forming medications. This is in contrast to the availability of commissioned services for patients who are dependent on illicit drugs and/or alcohol. remains there that The evidence confirmed that reduction or cessation of dependency-forming medications needs to be very carefully managed due to the risk of withdrawal symptoms and, in the context of the unchallenged evidence received, requires specialist input and training to maximise the prospects of success and to avoid potentially fatal consequences. The evidence, again unchallenged, was that the continuing absence of such a commissioned service gives rise to the risk of avoidable future deaths. 2 The long-standing and continuing lack of commissioned services in primary or secondary care for assisting people to safely reduce and withdraw from such prescribed medication was confirmed in her evidence by the Director of Pharmacy and Medicines Optimisation within the Mid and South Essex Integrated Care Board (the ICB). This witness helpfully set out important steps currently proposed and/or being taken to educate clinicians and service users alike of the dangers of opiate based prescription medications (alongside their relatively limited benefits in most, though not all, cases) with a view to reducing the size of the cohort of patients at risk of becoming dependent/addicted in the medium and longer term. However, this does not - absent a commissioned service to which GPs and patients may turn for specialist advice and assistance - address the immediate and on-going risk of future deaths to those currently dependant on/addicted to these medications, with the numbers of such patients having significantly increased in the post-COVID 19 period as a consequence of lengthy delays to, for example, chronic pain-relieving surgery. Precisely this issue was highlighted in a previous PFD Report from 14th November 2019 issued by the former Senior Coroner in this jurisdiction. The response from the (then) Clinical Commissioning Group had indicated an intention to roll-out a Prescribed Opioid Dependence Local Enhanced Service in early 2020, but this was not implemented due to the COVID 19 pandemic. Since then, including at the date of Mr Barry’s death in November 2023 and through to today, there remains no such, or similar, commissioned service across Essex or, it appears, consistently across England and Wales with only rare pockets around the country where such a service is commissioned. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Thursday August 7th 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. 6 7 8 COPIES and PUBLICATION 3 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons and others: The Family of the Deceased Essex Partnership NHS Foundation Trust Fern House Surgery I am also under a duty to send the Chief Coroner a copy of your response. 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 HM Area Coroner for Essex Sean Horstead 12.06.2025 4
3 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.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU HM Coroner Mr Sean Horstead Essex and Thurrock Coroner’s Service, Essex County Council, Seax House, Victoria Road South, Chelmsford, CM1 1QH 18th August 2025 Dear Mr Horstead, Thank you for the Regulation 28 report of 12th June 2025 sent to the Department of Health and Social Care about the death of Michael Paul Barry. I am replying as the Minister with responsibility for prescribing. I would like to take this opportunity to say how saddened I was to read of the circumstances of Mr Barry’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. Your report raises concerns over the lack of specialist commissioned services available to GPs for onward referral of patients requiring assistance with management of dependency- forming medicines. Specifically, a lack of services focused on reducing intake of prescribed dependency-forming medications and those offering specialist advice. Your report also highlights that the reduction or cessation of prescriptions for dependency- forming medications needs to be very carefully managed, due to the risk of withdrawal symptoms. Reduction and cessation of such medications requires specialist input and training to maximise the prospects of success and to avoid potentially fatal consequences. In preparing this response, my officials have made enquiries with NHS England and the Medicines and Healthcare products Regulatory Agency (MHRA) to ensure that your concerns have been adequately addressed. First, regarding the lack of specialist commissioned services available to GPs, NHS England has advised that the Prescribed Opioid Dependence Local Enhanced Service referenced in your report has been a locally proposed initiative that was not commissioned nationally. Therefore, whilst I do understand your concerns on this matter, NHS England is not able to comment on this specific service. NHS England has said that the Essex Partnership University NHS Foundation Trust (the Trust) recognises the growing concern around dependence on prescribed medication, particularly following the COVID-19 pandemic, during which access to elective procedures and chronic pain management services was disrupted. The Trust agrees that the safe reduction or cessation of these medications requires clinical expertise and coordinated care planning to reduce the risk of harm, including the potential for serious withdrawal effects and, in some cases, avoidable deaths. At present, however, the Trust is not commissioned to provide a specialist service for a stand-alone prescription medication dependency service that would allow direct referral from GPs solely for tapering and withdrawal management of these medicines. I would like to take this opportunity to detail what initiatives are in place by key organisations to address the wider areas of concern raised by your report. I have detailed these below. NHS England The Government commissioned a review into the use of medication and overprescribing. The outcome of this work, titled the National overprescribing review report, was published in September 2021. The report evaluated the extent, causes and consequences of overprescribing and made 20 recommendations to address it. NHS England and partner organisations have been implementing the review’s recommendations over the past 3 years, aiming to achieve long term sustainable reductions to overprescribing via delivery of systemic and cultural improvements within the NHS. A number of interventions are being delivered by NHS England to address and reduce overprescribing including: • Publication of the National medicines optimisation opportunities for the NHS in 2024/25, which includes an opportunity on chronic non-cancer pain management without opioids. ICBs have been encouraged to select opportunities for delivery. • Support for delivering Structured Medication Reviews (SMR). • A national programme to offer non-pharmacological alternatives such as social prescribing, as well as funding for social prescribers through the ARRS. Social prescribing is demonstrated to support patients address wider determinants of health which may be an underlying or contributory factor to the inappropriate use of medication. The NHS Medicines Safety Improvement Programme (which forms a key part of the NHS Patient Safety Strategy) is also delivering a focussed programme of work relating to the improved care of people with chronic pain and a reduction in the use of prescribed opioids. The programme has been in place since January 2021. The national programme is supporting Integrated Care Systems to learn from, adapt and adopt effective practice using a whole-system improvement approach. In March 2023, NHS England published ‘Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for ICBs and primary care’. This framework includes five actions, resources and case studies to help systems develop plans that can support people who are taking medicines associated with dependence and withdrawal symptoms, including opioids, by: • Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms. • Informing ICB improvement and delivery plans, when commissioning services and developing local policies that offer alternatives to medicines in the first place and/or support patients experiencing prescribed drugs dependence or withdrawal. • Ensuring a whole system approach and pathways involving multiple interventions, to improve care for people prescribed medicines associated with dependence and withdrawal symptoms. Across 2022 and 2023, 18 Integrated Care Systems received intensive support to develop and implement improvements in care and a further 15 participated in shared learning events. Commissioning of services to support people with chronic pain (including services to support people to safely withdraw from prescribed medicines that may cause dependence and withdrawal) now lies with Integrated Care Boards (ICBs). NHS England expects ICBs to commission appropriate services to meet the needs of the population that the ICB geographically covers. This includes taking due regard to any of the above national commissioning or clinical guidance. Controlled Drugs Accountable Officers and Controlled Drugs Local Intelligence Networks In light of the information provided by NHS England, I hope you will find it helpful if I explain the safeguards currently in place to ensure that healthcare organisations adopt safe practice in this area. NHS England has a clear responsibility in providing systems oversight for the management and use of controlled drugs, including opioids such as codeine. I am aware that NHS England’s Controlled Drugs Accountable Officers (CDAOs) undertake this role within each geographical region across England. They provide assurance that all healthcare organisations, including GP practices and pharmacies, adopt a safe practice for appropriate clinical use, prescribing, storage, destruction and monitoring of controlled drugs. CDAOs facilitate the routes to share concerns, report incidents, and take remedial action as well as highlighting good practice. This is shared with wider partners such as Integrated Care Boards and the police through the Controlled Drugs Local Intelligence Networks (CD LINs). Details of all CDAOs in England are held on a national register, which is owned and published by the Care Quality Commission: www.cqc.org.uk/content/controlled-drugs- accountable-officers. National Institute for Health and Care Excellence As you may already be aware, the National Institute for Health and Care Excellence (NICE) is the independent body responsible for developing evidence-based guidance for the NHS and is responsible for developing guidance in line with established methods and processes. NICE guidelines are based on a thorough assessment of the available evidence and are developed through a rigorous process, that includes extensive engagement with stakeholders and expert input throughout the guideline development process. NICE has published guidelines on the assessment and management of chronic primary pain and the safe prescribing and withdrawal management of medicines associated with dependence of withdrawal symptoms. These guidelines can be found here: • Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain • Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults. NICE guidelines describe best practice and the government expects NHS commissioners to take them into account in designing services that meet the needs of their local populations. It is however important to note that NICE guidelines are not mandatory and do not override a clinician’s responsibility to make decisions appropriate to the individual needs of their patients. Commission for Human Medicines As with any patient dependent on an opioid medicine, cessation of treatment should be undertaken slowly under the supervision of a healthcare professional to prevent the potential from withdrawal reactions. In 2020, following a review of addiction and dependence to opioids by the Opioid Expert Working Group of the Commission for Human Medicines, consistent warnings were added to product information to include this guidance. In addition, MHRA published a Drug Safety Update article for healthcare professionals and a leaflet which healthcare professionals are encouraged to give to patients. The MHRA continues to review the safety and access to codeine and will take regulatory action if considered appropriate. Managing co-occurring substance use and mental health As you mentioned in your report, Mr Barry had a long-standing history of mental health problems and illicit drug and alcohol misuse. Therefore, I hope you will find it helpful if I explain the actions being taken more broadly for those with substance use and mental health needs. Following a recommendation from Dame Carol Black’s independent review of drugs in 2020, the Department has been developing a comprehensive action plan to set out a path to improving service provision for those with co-occurring substance use and mental health needs. NHS England and the Department have worked with subject matter experts, including people with lived experience, academics, clinicians, and service providers in creating this plan. The plan is aimed to be as inclusive as possible and is built on the principles of ‘Everyone’s job’ and ‘No wrong door’. The first principle, ‘Everyone’s job’, states that commissioners and providers of mental health and alcohol and drug treatment services have a joint responsibility to meet the needs of people with co-occurring conditions by working together to treat those with mental health conditions as well as substance use conditions. The second principle, ‘No wrong door’, states that providers in alcohol and drug treatment, mental health and other services have an open-door policy for individuals with co-occurring conditions and make every contact count. Treatment for co-occurring conditions is available through every contact point and services should be working together seamlessly to meet needs. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH (SECONDARY CARE)
10 July 2025 Mr Sean Horstead HM Area Coroner HM Coroner's Office County Hall Seax House Victoria Road South Chelmsford CM1 1QH Dear Mr Horstead, Re: Regulation 28 Report to Prevent Future Deaths Thank you for your Regulation 28 Report dated 12 June 2025 concerning the tragic death of Mr Michael Paul Barry. We would like to express our sincere condolences to Mr Barry’s family and assure you that we have taken your concerns extremely seriously. Summary of Concerns We note your findings regarding the absence of a commissioned specialist service to support patients in primary care with the safe reduction and withdrawal from dependence-forming prescribed medications. We also acknowledge the contrast with the availability of services for those dependent on illicit substances and alcohol, and the associated risks of unmanaged withdrawal. Our Response The Mid and South Essex Integrated Care Board (ICB) is committed to improving patient safety and outcomes across all areas of care. However, as with all healthcare systems, we must continually balance a wide range of competing priorities, including urgent and emergency care, mental health, cancer services and cardiovascular disease. While the issue of dependence-forming medications remains a significant concern, and we are taking meaningful steps to address it, the pace and scale of service development are inevitably influenced by the need to allocate limited resources across multiple areas of critical need. Nonetheless, we fully recognise the risks highlighted in your report and remain committed to reducing harm and improving support for patients affected by medication dependency. The ICB has adopted a multi-faceted strategy to address the risks associated with prescribed dependence-forming medications, particularly opioids. Our approach includes: 1. Prevention and Education The ICB continues to prioritise prevention as a key strategy in reducing harm from dependence-forming medications. This includes reducing the number of patients initiated on opioids and supporting clinicians with education and tools to manage prescribing safely. In 2024, the ICB led the East of England-wide communications campaign “Pain Killers Don’t Exist”,1 aimed at educating the public on the risks of long-term high-dose pain medication and empowering individuals to make informed decisions. Thus, seeking to reduce the number of patients seeking to be prescribed dependence forming medications. Concurrent to this, regionally funded accredited Dependence Forming Medications (DFM) e- learning on ‘Reducing opioids in chronic pain’ and ‘Cognitive Behavioural Therapy for persistent pain’ training was offered to all practices through a locally commissioned Medicines Optimisation Local Enhanced Scheme in 2023-24. As further support for clinicians treating patients who are prescribed dependence forming medications, the ICB has developed and disseminated comprehensive guidelines for the management of acute and chronic non-malignant pain, including specific guidance on Opioid Tapering for Chronic Non-Cancer Pain. These resources provide a structured framework for identifying at-risk patients and supporting safe withdrawal. In addition, links to community services—many of which are self-referral—are made available to patients through primary care. The ICB will continue with its successful prevention of harm strategy to reduce the overall number of patients taking dependence-forming medications. Public information to support this strategy can be found on our website.2 2. Service Development A new Opioid Reduction/Discontinuation Pathway is planned within the Community Musculoskeletal (MSK) Service, currently in procurement and due for implementation in February 2026. This pathway will provide structured, face-to-face support to patients, including the development of personalised deprescribing plans, regular reviews, and coordination with GPs to avoid duplication of prescriptions. Patients on high-dose opioids (≥120mg/day morphine equivalent) will remain under the service until safely stabilised. Where appropriate, referrals will be made to mental health or addiction services. The ICB Executive Committee has endorsed a proposal to work up a business case to scale up the Aegros Primary Care Network (PCN)-based model across the ICB, aiming to deliver this service affordably while maintaining a primary care focus and upskilling clinicians to both deprescribe and prevent new cases of dependency. Conclusion We recognise the urgency of addressing the risks identified in your report and are committed to implementing sustainable, system-wide solutions. While the absence of a fully commissioned specialist service remains a challenge, we are actively working to bridge this gap through innovative models, education, and integrated care pathways. 1 https://www.midandsouthessex.ics.nhs.uk/health/campaigns/painkillers-dont-exist/ 2 https://www.midandsouthessex.ics.nhs.uk/health/personalised-care/medicines-management/drugs-of-dependence/ 2 We trust this response provides assurance of our commitment to improving care for patients at risk of harm from dependence-forming medication and so preventing future deaths. Yours sincerely Executive Medical Director Mid and South Essex Integrated Care Board Clinical Leadership and Innovation Directorate 3
Mr Sean Horstead
HM Area Coroner
Essex & Thurrock Coroner’s Service
Essex County Council
Seax Houe
Victoria Road South
Chelmsford
CM1 1QH
Co-National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
29 July 2025
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Michael Paul Barry who
died on 2 September 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 12
June 2025 concerning the death of Michael Paul Barry on 2 September 2023. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Michael’s family and loved ones. NHS England is
keen to assure the family and yourself that the concerns raised about Michael’s care
have been listened to and reflected upon.
Your Report raises the concern that there is ‘no specialist commissioned service
available for GPs to which they might refer their patients to manage reduction of their
of intake of prescribed dependency-forming medications’. This is in contrast to the
available commissioned services for patients dependent on illicit drugs and/or alcohol.
National role
NHS England remains aware of this important issue and has worked at a national level
to provide guidance and support across the NHS. In particular, NHS England is
responsible for providing oversight of the management and use of controlled drugs,
including opioids such as codeine. NHS England’s Controlled Drugs Accountable
Officers (CDAOs) undertake this role within each geographical region across England.
They provide assurance that all healthcare organisations, including GP practices and
pharmacies, adopt a safe practice for appropriate clinical use, prescribing, storage,
destruction and monitoring of controlled drugs.
CDAOs facilitate the routes to share concerns, report incidents and take remedial
action, as well as highlighting good practice. This is shared with wider partners such
as Integrated Care Boards (ICBs) and the Police through the Controlled Drugs Local
Intelligence Networks (CD LINs). Details of all CDAOs in England are held on a
national register, which is owned and published by the Care Quality Commission
(CQC): www.cqc.org.uk/content/controlled-drugs-accountable-officers.
Framework for prescribed dependency-forming medications
In March 2023, NHS England published ‘Optimising personalised care for adults
prescribed medicines associated with dependence or withdrawal symptoms:
Framework for action for ICBs and primary care’.
This Framework was developed for action with and for ICBs and primary care in
response to a Public Health England (PHE) review and recommendations (2019) and
NHS England’s subsequent analysis of the data up to 2020/21. NHS England’s
Framework was prepared in collaboration with organisations including the Department
of Health and Social Care (DHSC), CQC, National Institute for Health and Care
Excellence (NICE) and the Medicines and Healthcare products Regulatory Agency
(MHRA).
A range of stakeholders were consulted during the process, including patients with
lived experience and groups representing them, charities and voluntary sector
organisations involved in the provision of services in this area, clinical experts and
Royal Colleges.
The Framework includes five actions, resources and case studies to help healthcare
systems develop plans that can support people who are taking medicines associated
with dependence and withdrawal symptoms including opioids by:
• Optimising personalised care for adults who are prescribed medicines
associated with dependence or withdrawal symptoms.
•
Informing ICB improvement and delivery plans, when commissioning services,
and developing local policies that offer alternatives to medicines in the first
place and/or support patients experiencing prescribed drugs dependence or
withdrawal.
• Adopting a whole system approach and pathways
involving multiple
interventions, to improve care for people prescribed medicines associated with
dependence and withdrawal symptoms.
Additionally, NICE has published guidelines on:
• Chronic pain (primary and secondary) in over 16s: assessment of all chronic
pain and management of chronic primary pain (including guidance on
pharmacological management and the use of opioids for chronic primary pain).
• Medicines associated with dependence or withdrawal symptoms: safe
prescribing and withdrawal management for adults.
Overprescribing guidance
The National overprescribing review report was published in September 2021 and it
evaluated the extent, causes and consequences of overprescribing and made 20
recommendations to address it. NHS England and partner organisations have been
implementing the review’s recommendations over the past 3 years, aiming to achieve
long term sustainable reductions to overprescribing via delivery of systemic and
cultural improvements within the NHS.
A number of interventions are being delivered by NHS England to address and reduce
overprescribing including:
• Publication of the National medicines optimisation opportunities for the NHS in
for chronic non-cancer pain
to select
ICBs have been encouraged
includes an opportunity
2024/25, which
management without opioids.
opportunities for delivery.
• Support for delivering Structured Medication Reviews (SMR).
• A national programme to offer non-pharmacological alternatives such as social
prescribing, as well as funding for social prescribers through the Additional
Roles Reimbursement Scheme (ARRS). Social prescribing is demonstrated to
support patients in addressing wider determinants of health which may be an
underlying or contributory factor to the inappropriate use of medication.
Other developments
The NHS Medicines Safety Improvement Programme (which forms a key part of
the NHS Patient Safety Strategy) is also delivering a focused programme of work
relating to the improved care of people with chronic pain and a reduction in the use of
prescribed opioids. The programme has been in place since January 2021. The
national programme is supporting Integrated Care Systems to learn from, adapt and
adopt effective practice using a whole-system improvement approach.
In 2022/23, 18 Integrated Care Systems received intensive support to develop and
implement improvements in care, with a further 15 participating in shared learning
events.
Specialist commissioned service
The commissioning of services to support people with chronic pain (including services
to support people to safely withdraw from prescribed medicines that may cause
dependence and withdrawal) now lies with ICBs as a delegated specialised service.
NHS England expects ICBs to commission appropriate services to meet the needs of
the population that each ICB geographically covers. This includes taking due regard
of the above national commissioning and clinical guidance. A multi-disciplinary team
(MDT) approach is needed with input from, for example, pain specialists, dependence
services, mental health services and peer support groups. I note that your Report has
also been addressed to Mid and South Essex ICB and trust that they will be able to
respond further on this issue.
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
Michael, 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,
Co-National Medical Director
(Primary Care)
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