Marjorie Ellery

Dear Mr Wickens RE: Mrs Marjorie ELLERY (Deceased) Thank you for your letter dated 27th November 2014 and the attached Regulation 28 Prevention of Future Deaths Report relating to the above named. Thank you for the agreed extension of 2 weeks due to the Christmas and New Year holidays. Regulation 28 highlighted 2 areas of concern: Action is required to ensure that medication is not administered to patient to which are known to have an without advice being sought from a doctor of appropriate designated seniority or experience Action is required to ensure that informed consent obtained from patient as to the administration of medication to which there is a known allergy We have reviewed the concerns raised following the inquest into Mrs Ellerys death and have outlined below the Trust'$ position in relation to the 2 points raised The Trust has made the decision that any patient who requires a medication that they are known to have an allergy to, the decision to give this medication must be authorised by registrar or above and documented in the notes A discussion with the patient must be undertaken by the medical team and consent gained from the patient (if able) or discussed with a relative where applicable and documented in the medical notes and signed by the patient_ patient's red wrist band which denotes an allergy include the name of the and the reaction but no more than 2 drugs recorded on one wrist band_ These significant changes in practice have been presented to, and agreed at, both the Trust Quality Safety Committee and Medication Safety Committee_ The guidance on allergies was included in the Trust's Record Keeping Guideline but as a result of these changes in practice a new policy has been developed on The they allergy drug must The

Commilted xcellence Working Together Facing The Future Frimley Health [ NHS Foundation Trust the Management of Allergies: This is currently out for comment and will be ratified at the Medication Safety Committee on the 18th February 2015. These changes in practice have already been communicated to the medical teams by the Medical Director and the Lead nurses at a variety of Trust Forums and committees The monthly Patient Safety Training for all nursing staff has been reviewed and amended to include training on the management of allergies. In addition, the Trust is in the process of reviewing its current assessment competency for nursing staff to include the changes in practice as part ofthe theory and practical test. The Trust is committed to patient safety and takes cases such as this seriously hope this demonstrated in our response to the concerns you have raised. However, if | can be of any further assistance, please do not hesitate in contacting me