Robert Simpson

7th October 2025 

For the attention of Mrs Louise Hunt 
Senior Coroner for Birmingham and Solihull 

Dear Mrs Hunt 

Inquest touching the death of Robert Simpson 
Response to Regulation 28 Report to prevent future deaths 

I  am  writing  in response  to the  Regulation  28  notice issued following  the  conclusion  of the 
Inquest  on  7  August  2025  touching  the  death  of  Mr  Simpson  who  died  on  9  July  2024  at 
Heartland Hospital (part of University Hospitals Birmingham NHS Foundation Trust (UHB)).  

We have carefully considered the concerns raised within your report to prevent future deaths 
and would respond as follows. 

1.  It was accepted by the Trust that the deceased had been provided and discharged with 
medication (gabapentin) that did not belong to him and had missed two doses of antibiotics 
(fidaxomicin)  due  to  the  drug  being  out  of  stock,  which  had  not  been  communicated  to  or 
escalated to treating clinicians.  

The Trust does not dispute this and confirms, following the Trust patient safety investigation, 
that the deceased was discharged with the medication belonging to another patient and that 
two doses of antibiotics were not administered which had not been communicated or escalated 
to the relevant clinicians.  

2.  In evidence the Trust were unable to confirm whether the issues set out in 1. above sat 
solely with the nursing team or also involved pharmacy.  

As per the Medicines Code, nursing staff are expected to appropriately record patient’s own 
controlled drugs, conduct daily reconciliation as part of stock balance checks. This would have 
ensured that the medication (gabapentin) and its location were accounted for and would have 
prompted timely disposal if it was not suitable to be returned to the patient to whom it belonged, 
and this is where the deviation occurred.  

The  patient  safety  investigation  identified  that  Trust  medicines  processes  and  procedures 
were not followed by nursing professionals on this occasion. Specifically, the registered nurses 
(RN’s)  involved  in  the  admission  and  discharge  processes  for  both  Mr  Simpson  and  the 
previous  patient  did  not  comply  with  the  requirements  of  the  Trust  Medicines  Code  or  the 
patient safety checking processes set out in the Medicines Management ‘Fit for Discharge’ 
checklist.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 There are no actions UHB Pharmacy could have taken to prevent either of the missed doses 
as  the  incidents  occurred  out  of  normal  working  hours,  and  the  drug  was  available  in  the 
emergency drug cupboard and dispensed directly to the ward.  The expected standard for any 
omission of prescribed medication is that the omission is immediately escalated to the nurse 
in charge of the shift as per policy and procedure (medicine code).  

from 

At University Hospitals Birmingham NHS Foundation Trust, each hospital operates a system 
(Omnicell®)  giving  access  to  an  emergency  medicine  cupboard  which  contains  important 
medicines  (but  not  Controlled  Drugs),  that  may  be  needed  when  the  Pharmacy  is  closed. 
Access  to  the  cupboard  is  through  the  appropriate  senior  nurse  on  duty  for  the  site.  The 
practice  of  obtaining  medicines 
the  emergency  drug  cupboards  or  other 
wards/departments applies to both ward stock and non-stock items and can take place at any 
time  of  day  to  facilitate  urgent  doses  of  critical  medicines.  Urgent  critical  medicines  are 
supplied to requesting wards to avoid missed doses. The drug stock locator function on PICS 
or Pharmacy intranet page must be used to determine other areas that stock the medication 
required. The clinical site practitioner (nurse) must obtain supplies from the emergency drug 
cupboard / out of hours medicines cupboard. Where the medicine is not available within the 
emergency drug cupboard / out of hours medicines cupboard or as stock in another clinical 
area,  the  clinical  site  practitioner  will  permit  the  ward  to  contact  the  on-call  pharmacist  for 
advice and/or supply. In both missed dose incidents, appropriate Trust medicines processes 
were followed to access and obtain Fidaxomicin. The missed doses occurred due to nursing 
staff failing to record and communicate where the Fidaxomicin was being safely stored on the 
ward.  

3.  Whilst evidence was given in relation to the discharge nurse having undertaken reflection 
and a focus group being set up to explore improvements with discharge and planning there 
was no evidence as to how the wrong medication was provided to the deceased and whether 
this was a discharge only issue or also an issue with allocation and distribution of medication 
by pharmacy or by ward staff.  

The  incident  investigation  identified  that  the  supply  error  arose  because  a  previous  patient 
occupying  the  same  bedspace  had  been  issued  with  a  hospital  supply  of  gabapentin  on 
discharge.  That  patient’s  pre-admission  (community-supplied)  gabapentin  remained  in  the 
secure bedside locker between 4-28 June 2024 and was not removed by the registered nurse 
who discharged the patient, prior to Mr Simpson being admitted to the bedspace. At the time 
of  Mr  Simpson’s  discharge,  this  medication  was  removed  from  the  locker  and,  due  to 
inadequate checks by the discharging registered nurse, was mistakenly ‘returned’ to him as if 
it were his own or part of his prescribed discharge supply.  

This  ‘Fit  to  Discharge’  checklist  clearly  sets  out  the  steps  required  to  ensure  the  safe 
reconciliation  of  medicines  at  the  point  of  discharge.  It  involves  verifying  the  patient’s 
discharge letter or medication list and removing any inpatient medication and/or patient’s own 
medicines that are not required for discharge from the bedside secure patient locker. 

 
 
 
 
 
 
 
 A  spot  check  bedside  locker  audit  was  undertaken  following  the  incident  which  further 
identified ten medications that had not been sent home with patients upon discharge. Each 
medicine’s  breach  has  been  reported  and  investigated  to  ensure  all  patients  have  been 
provided  with  a  sufficient  supply  of  medications  and  that  these  medications  were  correctly 
labelled for the appropriate patient and verified against both the discharge letter and the list of 
medicines on the electronic prescribing and medicines administration system (PICs).    

4.  There was no evidence to explain how the deceased missed two doses of antibiotics due 
to the drug being out of stock, why treating clinicians were not informed or why an alternative 
antibiotic  was  not  administered  in  its  place.  The  Trust  were  unable  to  talk  to  what,  if  any, 
systems were in place to ensure that patients were not left without necessary medication.  

Fidaxomicin was available either on the ward, in main pharmacy or within the emergency drug 
cupboard at Solihull Hospital throughout Mr Simpson’s admission and was accessed as per 
the medicines code. On the 16 June 2024, the drug was in the bedside secure locker however 
nursing  handovers  had  failed  to  communicate  and/or  document  on  PICs  noting,  where  the 
medication was being securely stored and the RNs were not routinely checking the bedside 
lockers before administrations. In the event a registered nurse cannot locate a drug dose, then 
the  emergency  drug  cupboard  should  be  utilised.  Fidaxomicin  has  low  usage  as  it  is  a 
restricted  antibiotic  used  as  a  second  line  treatment  for  clostridium  difficile  or  on  the 
recommendation of a microbiologist.  Fidaxomicin is a high-cost medication (£1,600 for a box) 
and is therefore not recommended as a stock drug on any location across UHB clinical areas. 
However, it is available in all emergency drug cupboards, 24/7, across all UHB hospital sites.  

Mr Simpson was diagnosed with clostridium difficile from a stool specimen taken on 13 June 
2024 and a 10-day course of Fidaxomicin was advised by a Consultant Microbiologist, which 
was  the  prescribed  by  the  treating  team.  A  noting  was  added  to  PICS  (EPMA  Electronic 
Prescribing and Medicines Administration system) on 15 June 2024 at 18:50 by a registered 
nurse ‘Fidaxomicin not in stock ordered from pharmacy for tomorrow (16 June 2024) but also 
informed first on (Clinical Site Practitioner) to get from emergency cupboard for tonight. Will 
handover to night staff to chase’. Fidaxomicin is not kept as stock item on any ward at UHB 
so was obtained from the hospital emergency cupboard by a clinical site lead at 19:57. The 
first dose was prescribed at 18:46 and administered at 20:16.  

First missed dose  

On 16 June 2024, the 07:00 prescribed dose was not given by a registered nurse, and reason 
was recorded on PICs as ‘drug out of stock’. At 11:37 a pharmacy technician spoke to a ward 
staff member and confirmed  the ward had the Fidaxomicin as 20 tablets were checked out 
from the  emergency  cupboard the  day  before (15 June  2024) to the  ward, therefore,  stock 
was available  on  the  ward at  the time the dose was missed.  At  12:02  the  registered  nurse 
located  the  Fidaxomicin  and  confirmed  it  was  being  stored  in  the  patient’s  bedside  secure 
medication locker. There was no documented reason on PICs as to why the registered nurse 
did not immediately administer the missed dose from 07:00 once the Fidaxomicin had been 
located and the nurse did not discuss omitting the dose with the nurse in charge or escalate 
to medical staff. The dose was not given until the next prescribed dose at 17:00, administered 
by different registered nurse. 

 
 
 
 
 Second missed dose 

On 19 June 2024 Fidaxomicin was prescribed to be given at 17:00 but not administered by 
the  registered  nurse  with  reason  recorded  on  PIC’s  ‘drug  out  of  stock’.  There  is  no  further 
documentation regarding omission actions or escalation to medical colleagues, the nurse in 
charge  or  pharmacy  staff  by  the  registered  nurse.  On  20 June  2024,  pharmacy  issued  an 
additional supply of 12 tablets, following an order placed the previous evening by an RN (19 
June 2024), when the dose was missed, to supplement the 13 tablets already available on the 
ward  and  ensure  completion  of  the  prescribed  course.  The  omission  was  identified 
retrospectively by the senior infection control nurse (IPCN) on 24 June 2024 at 13:39. The 
IPCN noted on PICs there had been 2 missed doses and escalated to the nurse in charge a 
recommendation  that  the  prescription  be  reviewed  as  1  day  of  treatment  course  had  been 
omitted. This was actioned and the prescription was amended by a resident doctor on 24 June 
2024 to extend the treatment course to 27 June 2024.  Based on the administration record, 
there should have been 13 tablets remaining in the bedside locker at that time, sufficient to 
administer the required doses.  

Every  administration  was  being  completed  by  a  different  registered  nurse  so  there  was  no 
continuity of care in terms of medication administrations and communication of where the drug 
was being securely stored. Whilst nursing staff through the course of their actions and checks, 
appear to have concluded that the antibiotic was not available, stock was in fact present on 
the ward following its removal from the emergency cupboard. It was nevertheless recorded as 
‘out  of  stock’.  After  the  first  missed  dose,  the  medication  was  transferred  to  the  patient’s 
bedside locker, which should have prevented the second missed dose, as sufficient stock (13 
tablets)  should  have  been  available.  This  suggests  the  bedside  locker  was  never  checked 
prior to omitting doses. 

Every  effort  should  be  made  to  administer  prescribed  medicines  as  omission  of  certain 
medicines,  or  a  delay  in  dosing,  can  be  detrimental  to  a  patient’s  well-being.  Medicines 
identified  within  the  Trust  as  “time-critical”  medicines  should  never  be  delayed  or  omitted, 
unless clinically  contraindicated  or the  patient  refuses  medication.  Any  omission, refusal  or 
delay in the administration of time-critical medications must be discussed with the prescriber 
or relevant Physician and documented within the patient records.  A medicine that has been 
omitted  or  refused  on  two  consecutive  occasions  must  be  brought  to  the  attention  of  an 
appropriate prescriber and the omission/refusal documented in the patient’s records. Where 
the omission/refusal of a single dose is considered to be clinically significant e.g. medicines 
on  the  critical  list,  this  escalation  must  occur  immediately.  If  in  doubt,  the  registered 
professional must discuss with the prescriber or relevant physician. 

 
 
 
 
 
 
 
 
 
 
 
 5.  The coroner is concerned that there may still be a risk to life of patients within the trust if 
they  are  provided  with  the  wrong  medication  or  miss  necessary  doses  of  prescribed 
medication.  

These medicines omissions have been retrospectively reported on the Trust RADAR incidents 
system and immediate actions have been taken to address the procedural failings with the 
individual  responsible  nurses.  The  patient  safety  incident  and  learning  have  been  shared 
across surgical and medical inpatient clinical teams.  To strengthen awareness, a Trust patient 
safety  notice will  be  circulated  to  reinforce  the  process  for  obtaining  time-critical medicines 
both  in  and  outside  of  normal  working  hours,  to  reduce  the  risk  of  missed  administrations 
across the organisation. The notice will be shared in department Safety Huddles, Ward team 
meetings,  Newsletters,  Clinical  Assurance  and  Care  Quality  meetings.  Induction  training 
materials 
in  medicines  administration  will  be 
involved 
strengthened  to  emphasise  the  management  of  missed  doses  of  time-critical  medicines, 
including the requirement to escalate to the medical team where a dose is likely to be missed 
or has been omitted. The Trust Medicines Management Moodle training package is also under 
review, so will strengthen any sections on missed doses/time critical medications for all clinical 
substantive professionals. 

for  healthcare  professionals 

Compliance is monitored in real time on the Trust Clinical Dashboard which shows the ward 
performance  against  the  Trusts  overall  compliance.  Data  can  be  drilled  down  to  see  the 
individual  drug  omissions.  Standards  are  clearly  described  in  the  Clinical  Dashboard  help 
section.  Ward  leaders/managers  have  individual  processes  to  monitor  these  weekly.  Key 
Performance Indicator (KPI) compliance is reported at Hospital Site level (Clinical Assurance, 
Care  Quality  and  Quality  and  Safety  Meetings)  and  at  Group  level  (Group  Care  Quality 
Meeting). The monthly Group Clinical Dashboard Review Group (chaired by the Deputy Chief 
Nurse) reviews dashboard indicators and engages with wards that are both showing higher 
levels of omissions and lower levels of omissions to review their individual data and developed 
improvements  which  are  then  shared  Trust  wide  to  continually  improve  patient  safety  and 
quality of care. 

Day to day compliance is supported by the PICS system which defaults to the drug chart when 
a  registered  nurse  first  enters  the  patients  record.  This  was  developed  to  ensure  clear 
immediate identification of any missed medication. The Matrons and Ward/Unit leaders are 
responsible for  overseeing,  auditing  and  reporting  audit  outcomes  and  compliance through 
monthly Hospital Clinical Assurance and Care Quality meetings. These meetings are chaired 
by the Hospital Director and Associate Directors of Nursing. When areas are identified as not 
adhering to medicine standards and/or KPI’s, corrective actions and improvement plans are 
agreed,  monitored  and  compliance  reported  through  the  Hospital  and  Trust  Group  Care 
Quality Meetings.  

Compliance with the Medicines Code is audited by the following methods:  

•  RADAR records reported to each Safe Medication Practice Group meeting  
•  Missed Dose audits – every 6 months  
•  Controlled Drug audits in clinical areas – every 3 months  
•  Controlled Drug stock checking audits by clinical areas- monthly  
•  Safe Handling and Storage audits in Clinical Areas bi-annually 

 
 
 
 Medicines must only be administered to patients by registered practitioners or any healthcare 
staff  who  have  been  assessed  as  competent  in  the  administration  of  medicines.  Whilst  all 
registered staff within the inpatient wards have completed and been signed off as competent 
in  the  management  and  administration  of  medicines,  as  a  result  of  these  incidents,  all 
registered nurses within the  Trust  who  are  involved  in the  administration of  medicines,  are 
being  provided  additional  training  and  education  to  refresh  their  knowledge,  understanding 
and accountability relevant to their duties in drug administration in accordance with the Trust 
Medicines Code.  Clinical Practice Educators within the School of Nursing are in the process 
of preparing a Medicine Management Webinar which will be provided to the Ward Leaders 
and  Matrons  across  the  Trust.  The  leaders  and  managers  of  each  clinical  area  will  be 
responsible for  ensuring  that the  webinar  is  accessed  by  registered  nurses  as part  of their 
essential training updates.  The Matrons are responsible for ensuring that wards have the ‘Fit 
for Discharge’ checklist readily accessible within clinical areas, including at bed spaces and 
near patient medication lockers, where the discharge process is undertaken. This is to ensure 
that practice standards are consistently followed and adhered to. 

Registered practitioners are expected to practice in accordance with the standards set in the 
UHB  medicines  code,  and  by  their  relevant  UK  professional  bodies.  They  must  also 
acknowledge any limitations in their knowledge, skills or competence to administer or check 
medicines.  When  the  medication  error  was  reported  retrospectively  through  a  formal 
complaints  process  by  Mr  Simpsons  daughter,  the  Matron  and  Ward  Manager  initiated  an 
investigation. A retrospective medication incident form was completed and associated practice 
improvement  plan  was developed  at  Solihull  Hospital.   To  ensure  that  the findings,  actions 
and learning from these incidents are shared widely, the improvement plan mandates inclusion 
of all clinical areas, across the hospital and community sites. In addition, ongoing monitoring 
of  these  practices  will  be  conducted  through  the  hospital  Quality  and  Safety  Governance 
agenda.  

The registered nurses involved in the medication breaches have been individually counselled 
in accordance with the Trust’s Standards for Management of Medication Administration Errors. 
This counselling addresses their practice and non-adherence to established processes and 
procedures, ensuring staff fully understand their role, clinical responsibility and accountability 
when administering and dispensing discharge medications to patients.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Matrons and ward managers at Solihull Hospital are also undertaking spot check assessments 
of registered nurses’ practices when discharging patients from the medical and surgical wards. 
Outcomes  and  learning  opportunities  will  be  shared  and  discussed  within  the  Clinical 
Assurance monthly group meetings with nurse leaders and managers.  There have been no 
further reports of patients being discharged with incorrect medications, CDs not belonging to 
patients or medications belonging to another patient since this incident was raised at Solihull.  
The  incidents  have  demonstrated  several  patient  safety  risks  associated  with  the  storage, 
handling and checking of medicines within clinical areas across Solihull Hospital.  The safe 
and  secure  and  handling  of  medicines  (SaSHM)  is  audited  bi-annually  by  the  pharmacy 
department  across  the  Trust.  Compliance  against  SaSHM  standards  declined from  98% to 
82%  in  the  last  quarterly  audit  cycle  at  Solihull  Hospital  which  was  the  largest  decline  in 
performance across all the hospital sites. Ward managers, with the support of the respective 
speciality’s Matron, are responsible for developing and completing action plans based on the 
results of the audits and report progress against compliance within the monthly Care Quality 
agenda.  Audit  outcomes  have  demonstrated  areas of  operational  non-compliance  however 
there have been no patient safety incidents or harm resulting from the standards not being 
met. Assurance has been received that actions have been completed with immediate effect.  

Immediate  actions  have  been  taken  by  the  senior  nursing  managers,  clinical  leaders  and 
practice educators to monitor practice, share the learning from these incidents across all UHB 
Quality  and  Safety  forums/groups  as  well  as  developing  a  comprehensive  medicines 
management education and training refresher for all registered nurses alongside Pharmacy 
and clinical practice education leads.  

Monitoring  of  compliance  against  Trust  standards  will  be  undertaken  locally  through 
documentation,  discharge  and  bedside  assessments  and  audited  weekly  until  practice 
improvement,  standards  and  checks  described  in  the  Trust  Medicines  Code  take  place  on 
every  discharge  (3.2.6  Medicines  Code)  and  adhered  to.    Compliance  against  medicine’s 
standards is now being reported monthly through the Hospital’s Quality and Safety meetings 
and  Safe Medication  Practice Group.  Any  themes and practice  safety  risks  are  reported  to 
both the Group Care Quality and Medicines Management Advisory Group.   

I would like to assure you that the concerns raised within the Regulation 28 notice have been 
taken  extremely  seriously,  which  I  hope  is  demonstrated  in  the  steps  that  we  have  taken 
following Mr Simpson’s death. 

Yours sincerely 

Chief Executive Officer