Action Taken
The Trust has taken steps to ensure staff interactions with family carers recognise the risk of medication misuse and highlight it as an area to be considered. They have also recommended staff should ensure that when specific risks are identified in a person, this must be followed by comprehensive risk management care plans. (AI summary)
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Dear Mr Travers , Inquest into the death of Francis Andrade REGULATION 28 REPORT To PREVENT FUTURE DEATHS Further to the conclusion of the inquest into Mrs Andrade's death on July 2014, you wrote to Surrey and Borders Partnership NHS Foundation Trust in accordance with Regulation 28 report to prevent future deaths, stating that during the course of the inquest the evidence revealed matters giving rise to concern_ We would like to take this opportunity to continue to offer our sincere condolences to the Andrade family for their loss: The area of concern you raised that relates to our Trust and our response are detailed below: Where there_is a history_of_overdoses_being_taken bY_family_member_ using medication that_is_prescribed to family member B consideration should be_given to what_steps could_reasonably_ betaken to secure_that_medication_with a view to restricting access to it bY family member A Due to the limited influence we have on how members of the public store or manage their medication it will, unfortunately, be unrealistic for us to say we can fully mitigate against this risk going forward. We have however taken steps to ensure that our staff interactions with family carers and people using services recognise this risk and highlight it as an area to be considered by all parties involved_ Further to our own internal investigation we since recommended that staff should ensure that when specific risks are identified in a person [e.g: a person is assessed to be hoarding medication and using other person's prescribed medication to overdose], this must be followed by comprehensive risk management care planls in collaboration with the personls and shared with the Team directly involved in the person's care. We believe that a process managed through effective care planning arrangements with clear engagement with the person using our service and the carer, would be the most effective process that may go some way to mitigate this risk Forabetter life Trust Headquarters, 18 Mole Business Park, Leatherhead, Surrey KT22 7AD T_0300 55 55 222 F_01372 217111 WWWsabp nhs.uk 25th have
monitor compliance with care planning through our Board Performance Indicators to ensure that the process of care planning remains embedded. Our Home Treatment Team has developed a local protocol to ensure safety of medication management and further to the investigation they are expected to establish safety plan with the person and family for the safe storage of medication if history of overdosing on family's medication has been revealed. Further to the outcome of the inquest, we will be holding a workshop as part of our Suicide Prevention Action Group process to share the learning to wider group of clinical staff to ensure embedding of the learning: Our Board has been made aware of your letter and we would like to once again offer our sincere condolences to the Andrade family for their loss and hope that the steps we have taken as outlined above assures you and them, that we have learnt and continue to learn from Mrs Andrade's death Please do not hesitate to contact me or [Director of Quality (DoN) if you require any further information.