Doreen Willis

Dear Mr Arrow Following the inquest held on 5ih June 2017 in relation to the death of Mrs Doreen Willis, you have requested that the key learning outcomes pertaining to the care homes which were identified from the agency review are summarised: This will enable you to provide a report to the Care Quality Commission (CQC) sharing the learning that can be taken forward by care homes in relation to the medicines management processes within their settings. Please find below the areas of learning identified: Care homes must have appropriate medicines management policies and processes in place to ensure the timely and safe ordering, receipt, administration and recording of medicines management for their individual residents_ This should include all aspects of medicines reconciliation at each point or care transferltransaction. AIl staff within the care home involved in medicines management; including administration; are responsible for monitoring and checking the availability of ALL medicines required for individual residents_ Where a medicine is not available for administration there must be a clear process understood by all staff, of what actions and recording of actions should be taken to ensure the medicine is obtained as soon as possible. AIl actions in relation to medicines management must be recorded in the individuals care record and when a residents care transfers to another care provider the manager or responsible person should co-ordinate an accurate listing of all the resident's medicines as part of the onwards needs assessment and care plan: NICE guidance SC1 provides recommendations for good practice on the systems and processes for managing medicines in care homes and care homes should ensure their policies and processes align with this htts Ilniceorguklquidancelscl The introduction of Electronic Transfer of Prescriptions (EPS) systems are now being introduced across primary and community care settings and this reduces the risk of error at points of transferlhandover: This system reduces the need for fax or paper transfers and gives a full audit trail for each individual prescription. Care homes should be recommended to utilise electronic methods for ordering; receipt and reconciliation of medicines as a way of promoting resident safety in effective medicines management multi-_ key

We hope this information provides you with the learning from the multi-agency review undertaken: