Your Health Partnership Regis Medical Centre
Other
Action Planned
The practice will amend their risk assessment template to include a mental health medication review code and free text advice regarding stockpiled medications, patient safety with medication quantity, reducing medication amounts, and safety plans. They will relaunch the amended policy in January 2026 and add the recording of medication review and consideration of reducing amount of medication on each issue as part of the annual audit program. (AI summary)
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Lyndon Primary Care Centre Lower Lyndon West Bromwich West Midlands B71 4HJ Tel: 0121 553 0385 Great Bridge Health Centre Unit 18 Great Bridge Centre, Great Bridge Street West Bromwich West Midlands Tel: 0121 612 3650 Oakham Surgery 213 Regent Road Tividale West Midlands B69 1RZ Tel: 01384 458 968 Regis Medical Centre Darby Street Rowley Regis West Midlands B65 0BA Tel: 0121 559 3957 Mace Street Clinic Mace Street Cradley Heath West Midlands B64 6HP Tel: 01384 354 653 Whiteheath Medic Centre Badsey Road Oldbury West Midlands B69 1EJ Tel: 0121 612 270 Response to Regulation 28: Report to Prevent Future Deaths Coroner: Mrs Joanne Lees, Area Coroner for The Black Country Deceased: Danielle Monique Christina JONES Date:
22.12.2025 Timeline taken from patient record:
23.8.24 Medication review carried out with patient. No suicidal thoughts or thoughts of self harm. Mood ok with meds. Continue current repeat medication
24.2.25 Email received from Cranstoun to inform GP that patient had informed them she had taken an intentional overdose of her prescribed medication, had written notes to family members then changed her mind and made herself vomit.
4.2.25 1 month supply of repeat meds issued
24.2.25 Telephone consultation with Dr . Discussed overdose which patient stated had happened 3 weeks ago. The patient regretted the decision and made herself vomit immediately afterwards. Denies any current thoughts of self- harm. She stated she was currently living with her grandparents. Danielle was offered a face-to-face appointment on the same day, but stated she was unable to attend in person on the same day, so booked for the following day. The current details and information Danielle gave of the overdose were not consistent with the email received from Cranstoun. It is standard practice to complete the risk assessment contemporaneously with the patient based upon current mood, whilst mindful of previous information. This is to ensure an accurate and appropriate risk assessment is made at the time of the conversation.
25.2.25 Did Not Attend the face-to-face appointment
25.2.25 Follow up telephone call made by Dr Danielle stated she had not attended because she could not find her bus pass and credit on her phone had run out. Denies any current/active plans to self-harm and feels mental health is currently stable and managing. Crisis team number given-if thoughts of self-harm 999/A & E.
6.3.25 1 month supply of meds issued
27.3.25 1 month supply of repeat meds issued
28.4.25 1 month supply of repeat meds issued
13.5.25 Ambulance report received – death confirmed
14.5.25 Coroners office confirmed police had reported death
Lyndon Primary Care Centre Lower Lyndon West Bromwich West Midlands B71 4HJ Tel: 0121 553 0385 Great Bridge Health Centre Unit 18 Great Bridge Centre, Great Bridge Street West Bromwich West Midlands Tel: 0121 612 3650 Oakham Surgery 213 Regent Road Tividale West Midlands B69 1RZ Tel: 01384 458 968 Regis Medical Centre Darby Street Rowley Regis West Midlands B65 0BA Tel: 0121 559 3957 Mace Street Clinic Mace Street Cradley Heath West Midlands B64 6HP Tel: 01384 354 653 Whiteheath Medic Centre Badsey Road Oldbury West Midlands B69 1EJ Tel: 0121 612 270 YHP PCN aims to treat individuals presenting with acts of self-harm in line with NICE Quality Standards 34 regarding Self Harm. The principle underpinning this is pro-active follow up to prevent patient harm. Patients should be offered follow up with a doctor or physicians associate of their choice and offered continuity of care. The YHP clinical guideline regarding follow up of self-harm was launched in January 2014. The updated QS34 includes a suggestion that if a person presents to a service with self-harm and ongoing risk that organisation should pro-actively follow that person up within 48 hours. Based upon the above NICE guidance, YHP currently has a Standard Operating Procedure in place for our administrative teams to highlight any clinical correspondence received with any mention of attempted suicide or self-harm and forward to a GP for action. In this case an email was received from Cranstoun (local drug and alcohol team) informing us of recent overdose and concerns. This was immediately passed to the duty GP who arranged a same day GP telephone assessment. As detailed in the timeline, a Face-to-Face appointment for the same day was also offered, but declined by Danielle. However, a face-to-face appointment for the following day was booked. When Danielle did not attend this appointment, a follow up call was placed by the Dr Ananthram. This is in line with the Standard Operating Procedure. We acknowledge that although a risk assessment was carried out regarding current and future suicidal intent and plans as part of the same day appointment, the issue of medication was not specifically addressed. This issue has been discussed with the individual clinician involved and the system changes below will ensure that all clinicians will be aware of the need to review medication in similar cases in the future. These changes have will be made on 1st January 2026. This has been communicated to the clinicians via the monthly YHP Clinical Update Newsletter and in team meetings. We have undertaken an annual audit of compliance with proactive follow up following self-harm since
2014. The results of the audits have provided assurance that the process of proactive follow up is being followed by our clinicians. QS 34 states people who have self-harmed have an initial assessment of physical health, mental state, safeguarding concerns, social circumstances and immediate concerns about their safety. However, it does not specifically state they require a medication review. We have a self-harm risk assessment template built into our clinical system to aid clinicians in discussing this with patients. (see image below)
Lyndon Primary Care Centre Lower Lyndon West Bromwich West Midlands B71 4HJ Tel: 0121 553 0385 Great Bridge Health Centre Unit 18 Great Bridge Centre, Great Bridge Street West Bromwich West Midlands Tel: 0121 612 3650 Oakham Surgery 213 Regent Road Tividale West Midlands B69 1RZ Tel: 01384 458 968 Regis Medical Centre Darby Street Rowley Regis West Midlands B65 0BA Tel: 0121 559 3957 Mace Street Clinic Mace Street Cradley Heath West Midlands B64 6HP Tel: 01384 354 653 Whiteheath Medic Centre Badsey Road Oldbury West Midlands B69 1EJ Tel: 0121 612 270 We had not specifically included medication review as part of this template. We will amend our follow up policy to specifically mention the need for medication review at the time of pro-active follow up, and in particular to consider reducing the amount of medication per prescription if there is any ongoing risk of further self-harm and especially with high-risk medications. We will amend our risk assessment template to include a mental health medication review code and free text advice regarding the following with a free text box to record discussions. Do you have any stockpiled medications? Do you feel safe with your current medication quantity? Would reducing the number of medications per prescription reduce the risk of future harm?
Lyndon Primary Care Centre Lower Lyndon West Bromwich West Midlands B71 4HJ Tel: 0121 553 0385 Great Bridge Health Centre Unit 18 Great Bridge Centre, Great Bridge Street West Bromwich West Midlands Tel: 0121 612 3650 Oakham Surgery 213 Regent Road Tividale West Midlands B69 1RZ Tel: 01384 458 968 Regis Medical Centre Darby Street Rowley Regis West Midlands B65 0BA Tel: 0121 559 3957 Mace Street Clinic Mace Street Cradley Heath West Midlands B64 6HP Tel: 01384 354 653 Whiteheath Medic Centre Badsey Road Oldbury West Midlands B69 1EJ Tel: 0121 612 270 Can a safety plan be put in place e.g. can a friend or family member supervise your medications? We will re-launch this amended policy in January 2026 with our clinicians and add the recording of medic ation review and recording of consideration of reducing amount of medication on each issue as part of the annual audit program. The learning from this event will be shared with clinicians via our monthly clinical update but also added to the agenda of our next face to face protected learning event for our GP’s in the new year. This learning has also been shared with our Acute Trust patient safety team colleagues for wider dissemination of learning. We will continue to audit the proactive follow up of self-harm annually but include specific data on whether a medication review was completed and discussion was had regarding amounts of medications prescribed. Clinical Quality Lead Your Health Partnership PCN
22.12.2025 Timeline taken from patient record:
23.8.24 Medication review carried out with patient. No suicidal thoughts or thoughts of self harm. Mood ok with meds. Continue current repeat medication
24.2.25 Email received from Cranstoun to inform GP that patient had informed them she had taken an intentional overdose of her prescribed medication, had written notes to family members then changed her mind and made herself vomit.
4.2.25 1 month supply of repeat meds issued
24.2.25 Telephone consultation with Dr . Discussed overdose which patient stated had happened 3 weeks ago. The patient regretted the decision and made herself vomit immediately afterwards. Denies any current thoughts of self- harm. She stated she was currently living with her grandparents. Danielle was offered a face-to-face appointment on the same day, but stated she was unable to attend in person on the same day, so booked for the following day. The current details and information Danielle gave of the overdose were not consistent with the email received from Cranstoun. It is standard practice to complete the risk assessment contemporaneously with the patient based upon current mood, whilst mindful of previous information. This is to ensure an accurate and appropriate risk assessment is made at the time of the conversation.
25.2.25 Did Not Attend the face-to-face appointment
25.2.25 Follow up telephone call made by Dr Danielle stated she had not attended because she could not find her bus pass and credit on her phone had run out. Denies any current/active plans to self-harm and feels mental health is currently stable and managing. Crisis team number given-if thoughts of self-harm 999/A & E.
6.3.25 1 month supply of meds issued
27.3.25 1 month supply of repeat meds issued
28.4.25 1 month supply of repeat meds issued
13.5.25 Ambulance report received – death confirmed
14.5.25 Coroners office confirmed police had reported death
Lyndon Primary Care Centre Lower Lyndon West Bromwich West Midlands B71 4HJ Tel: 0121 553 0385 Great Bridge Health Centre Unit 18 Great Bridge Centre, Great Bridge Street West Bromwich West Midlands Tel: 0121 612 3650 Oakham Surgery 213 Regent Road Tividale West Midlands B69 1RZ Tel: 01384 458 968 Regis Medical Centre Darby Street Rowley Regis West Midlands B65 0BA Tel: 0121 559 3957 Mace Street Clinic Mace Street Cradley Heath West Midlands B64 6HP Tel: 01384 354 653 Whiteheath Medic Centre Badsey Road Oldbury West Midlands B69 1EJ Tel: 0121 612 270 YHP PCN aims to treat individuals presenting with acts of self-harm in line with NICE Quality Standards 34 regarding Self Harm. The principle underpinning this is pro-active follow up to prevent patient harm. Patients should be offered follow up with a doctor or physicians associate of their choice and offered continuity of care. The YHP clinical guideline regarding follow up of self-harm was launched in January 2014. The updated QS34 includes a suggestion that if a person presents to a service with self-harm and ongoing risk that organisation should pro-actively follow that person up within 48 hours. Based upon the above NICE guidance, YHP currently has a Standard Operating Procedure in place for our administrative teams to highlight any clinical correspondence received with any mention of attempted suicide or self-harm and forward to a GP for action. In this case an email was received from Cranstoun (local drug and alcohol team) informing us of recent overdose and concerns. This was immediately passed to the duty GP who arranged a same day GP telephone assessment. As detailed in the timeline, a Face-to-Face appointment for the same day was also offered, but declined by Danielle. However, a face-to-face appointment for the following day was booked. When Danielle did not attend this appointment, a follow up call was placed by the Dr Ananthram. This is in line with the Standard Operating Procedure. We acknowledge that although a risk assessment was carried out regarding current and future suicidal intent and plans as part of the same day appointment, the issue of medication was not specifically addressed. This issue has been discussed with the individual clinician involved and the system changes below will ensure that all clinicians will be aware of the need to review medication in similar cases in the future. These changes have will be made on 1st January 2026. This has been communicated to the clinicians via the monthly YHP Clinical Update Newsletter and in team meetings. We have undertaken an annual audit of compliance with proactive follow up following self-harm since
2014. The results of the audits have provided assurance that the process of proactive follow up is being followed by our clinicians. QS 34 states people who have self-harmed have an initial assessment of physical health, mental state, safeguarding concerns, social circumstances and immediate concerns about their safety. However, it does not specifically state they require a medication review. We have a self-harm risk assessment template built into our clinical system to aid clinicians in discussing this with patients. (see image below)
Lyndon Primary Care Centre Lower Lyndon West Bromwich West Midlands B71 4HJ Tel: 0121 553 0385 Great Bridge Health Centre Unit 18 Great Bridge Centre, Great Bridge Street West Bromwich West Midlands Tel: 0121 612 3650 Oakham Surgery 213 Regent Road Tividale West Midlands B69 1RZ Tel: 01384 458 968 Regis Medical Centre Darby Street Rowley Regis West Midlands B65 0BA Tel: 0121 559 3957 Mace Street Clinic Mace Street Cradley Heath West Midlands B64 6HP Tel: 01384 354 653 Whiteheath Medic Centre Badsey Road Oldbury West Midlands B69 1EJ Tel: 0121 612 270 We had not specifically included medication review as part of this template. We will amend our follow up policy to specifically mention the need for medication review at the time of pro-active follow up, and in particular to consider reducing the amount of medication per prescription if there is any ongoing risk of further self-harm and especially with high-risk medications. We will amend our risk assessment template to include a mental health medication review code and free text advice regarding the following with a free text box to record discussions. Do you have any stockpiled medications? Do you feel safe with your current medication quantity? Would reducing the number of medications per prescription reduce the risk of future harm?
Lyndon Primary Care Centre Lower Lyndon West Bromwich West Midlands B71 4HJ Tel: 0121 553 0385 Great Bridge Health Centre Unit 18 Great Bridge Centre, Great Bridge Street West Bromwich West Midlands Tel: 0121 612 3650 Oakham Surgery 213 Regent Road Tividale West Midlands B69 1RZ Tel: 01384 458 968 Regis Medical Centre Darby Street Rowley Regis West Midlands B65 0BA Tel: 0121 559 3957 Mace Street Clinic Mace Street Cradley Heath West Midlands B64 6HP Tel: 01384 354 653 Whiteheath Medic Centre Badsey Road Oldbury West Midlands B69 1EJ Tel: 0121 612 270 Can a safety plan be put in place e.g. can a friend or family member supervise your medications? We will re-launch this amended policy in January 2026 with our clinicians and add the recording of medic ation review and recording of consideration of reducing amount of medication on each issue as part of the annual audit program. The learning from this event will be shared with clinicians via our monthly clinical update but also added to the agenda of our next face to face protected learning event for our GP’s in the new year. This learning has also been shared with our Acute Trust patient safety team colleagues for wider dissemination of learning. We will continue to audit the proactive follow up of self-harm annually but include specific data on whether a medication review was completed and discussion was had regarding amounts of medications prescribed. Clinical Quality Lead Your Health Partnership PCN