Samantha Gould

Dear Mr Moss, Re: Regulation 28 Report to Prevent Future Deaths – Samantha Jane Gould, died 2 September 2018 Thank you for your Regulation 28 Report to Prevent Future Deaths (hereafter “report”) dated 28 May 2021 concerning the death of Ms Samantha Gould on 2 September 2018. Firstly, I would like to express my deep condolences to Ms Gould’s family. I am very sorry it has taken so long to respond and would be grateful if you would convey my apologies to Ms Gould’s parents. Your report concludes Ms Gould’s death was a result of suicide by an overdose of prescribed medication with a wider narrative as follows: “There was a systemic weakness and failing in the lack of a protocol for [Child and Adolescent Mental Health Service – CAMHS] and the GP service to communicate with local pharmacies concerning 16-18 year old patients with mental health conditions who were at risk of deliberate overdose. Sam was therefore able to pick up older prescriptions on 1 September 2018 without challenge. It was those medications … that were fatal in the combined amounts Sam ingested on the night of 1-2 September 2018.” Following the inquest you raised concerns in your report to NHS England and NHS Improvement (NHS E/I) regarding the following points: Point 1: There did not appear to be any national guidance or standards that directed or encouraged appropriate sharing of risk information and care plans with the local pharmacy. As a result, the pharmacy was unsighted on the fact that the treating psychiatric team had a safety plan involving Sam’s parents being responsible for handling and administering all medication. Had the pharmacy been aware of this plan, it is likely that they would either have refused to provide the medication with which Sam overdosed or, at least, contacted Sam’s parents or General Practitioner. National Medical Director NHS England & NHS Improvement and Interim Chief Executive of NHS Improvement Skipton House 80 London Road London SE1 6LH 8th September 2021

Point 2: A local protocol has now been introduced whereby the Cambridgeshire and Peterborough Foundation Trust’s Child and Adolescent Mental Health Service ensures that any pharmacy used regularly by their patients aged 16-17 are (where appropriate) advised of relevant care plans, as well as the responsible GP being so informed. This is now to be part of mandatory training for CAMHS prescribing staff and is to be discussed in the local Joint Prescribing Group to ensure better communication between the local NHS Trusts, G.P.s and local pharmacies. Accordingly, action has already been taken in the local area to prevent similar fatalities.

Point 3: I am concerned that there is a risk of future fatalities if action is not taken at a national level to ensure that pharmacies are appropriately involved in medication safety plans for mental health patients aged 16 – 17, given that such patients may otherwise be able to obtain prescribed medication with which to overdose.

I have set out in the annex some information that is relevant to this tragic incident and if used appropriately will help us ensure the risk of this tragic incident happening again is minimised. To assist in this I have asked Dr , Deputy Chief Pharmaceutical Officer, to establish a working group to build on the work of the Joint Prescribing Group you mention, with the aim of rolling it out, or an improved approach, across the country within the next 6 months, and then subsequently to ensure that facilities like the Summary Care Record and other digital means are used to their full benefit.

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.

Dear Mr Moss, Inquest into the death of Samantha Gould – regulation 28 notice Thank you for providing us with a copy of your report dated 28 May 2021, regarding the tragic death of Samantha Gould. First and foremost, I would like to express my sincere condolences to the family of Samantha. By way of information, the Company Chemists’ Association Limited (CCA) is a trade association representing the interests of large multiple community pharmacies. Our members are Asda, Boots, LloydsPharmacy, Morrisons, Rowlands, Superdrug, Tesco and Well. The CCA represents the interests of its members and provides a forum to bring together their knowledge, skills, resources, and experience for the benefit of patients and the NHS. The CCA does not operate any community pharmacies, nor do we set standards or provide guidance for our members or other pharmacy operators. As such we are, unfortunately, not in a position to undertake direct action in this regard. Having said this, the CCA provides the secretariat for the Community Pharmacy Patient Safety Group (CPPSG). This non-statutory Group brings together representatives from the 19 largest community pharmacy organisations to work together to promote patient safety. The CPPSG is driven by the principles of sharing and learning. The Group will discuss this tragic incident at its next meeting in July. They will consider Samantha’s case to identify learnings and share best practice so that the risk of similar events can be prevented. A summary of this discussion will be shared with the community pharmacy network nationally via members of the group’s internal communications channels and via the trade press. This regulation 28 notice raises an important question about sharing of information and the inclusion of community pharmacy in care planning processes. Whilst neither the CCA nor the Patient Safety Group has legislative authority to change processes, we do share your concerns. We will work with the other organisations identified in your report (the GPhC, RPS and NHS England) to further consider how practice can be improved. If there is anything else that you would like us to do in this regard, then please do not hesitate to contact me.