Stretton Branch Surgery
Other
Action Planned
The practice will audit care plans every 6 months, request GP review earlier than 2 weeks if needed, refer to CRISIS team for deterioration, have the Clinical pharmacist assist with medication review and arrange a follow-up appointment for any patients that DNA. (AI summary)
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Dear Ms Davies I write on behalf of the Stretton Medical Centre in response to your Regulation 28: report to prevent future deaths, dated 14 December 2023. We would like to thank you for bringing your concerns to the attention of the Practice and we wish to reassure you that the care and support of our patients is of the utmost importance to us. As a Practice, we were extremely saddened by Olivia’s death, and we wish to once again offer our sincere condolences to Olivia’s family. On 2 January 2024, the Practice conducted a clinical meeting / significant event meeting with our GP principal, , our salaried GP, , our regular Locum doctor, was unable to attend in person as she was working as locum doctor elsewhere at the time. We, as a practice, updated her on the discussion and the outcome. The purpose of the meeting was to discuss the outcome of the inquest and discuss the information and concerns detailed in the Regulation 28 report. We have considered the concerns and our response and action to each is below:
1. There was no Significant Event Meeting following Olivia’s death: The original information received from the hospital as notification of Death had limited information and detailed cause of death as cardiac arrest rather than apparent suicide. Therefore, at the time of Olivia’s death, a Significant Event Meeting was not carried out as the Practice awaited further information from the hospital report.
Stretton Medical Centre Stretton Branch Surgery 5 Hatton Lane Stretton 43-45 Dudlow Green Road Warrington Appleton WA4 4NE Warrington WA4 5EQ
A SEA was conducted on 2 January 2024. The Practice accepts that an SEA should have been performed sooner and prior to the inquest to ensure that learning from the death was identified as soon as possible and changes made to systems or practice where required. This was an oversight on our part, and the Practice would like to apologise for the delay. This learning is shared with all the clinicians in our practice and will be shared with clinicians in our primary care network for peer review. The Practice would like to reassure you that all patient deaths will be discussed at our monthly MDT meeting. We have revised our monthly Clinical Team Meeting template and every unexpected death will be discussed with a view to complete a Significant Event Analysis on them to share any learning. Where appropriate, the Significant Event Analysis of a death will be completed in a month, ready to discuss in the next monthly Clinical Team Meeting.
2. To ensure relevant information is shared with a patient when commencing an antidepressant, in accordance with relevant clinical guidelines. This includes a discussion about risks, in particular the risk of relapse when stopping a medication and the risk of increased self- harm ideation at the outset of treatment. As a result of the SEA on 2 January 2024, NICE Guidance (NG222 – Depression in adults: treatment and management) has been recirculated to all clinicians highlighting the need to appropriately discuss with patients any risks and in particular, the risk of relapse. Also, we shared a copy of the General Medical Council’s guidance on prescribing to doctors. We have implemented a system whereby whenever an antidepressant or an anti- anxiety medication is prescribed a note will be added to patient and pharmacist to confirm “please do not stop these medications without medical advice”. This note will show up on the medication box label. We have reminded all GPs that at the time of commencing an antidepressant, they should have a conversation with the patient mindful of the relevant clinical guidelines. The GP is then to book a follow up review with the patient. We have included this reminder in new starters and locum induction pack to ensure they act accordingly.
Stretton Medical Centre Stretton Branch Surgery 5 Hatton Lane Stretton 43-45 Dudlow Green Road Warrington Appleton WA4 4NE Warrington WA4 5EQ
To ensure risks are discussed with patients on anti-depressant medication, the Practice recognises that appointment times would need to be extended beyond the usual 10-minute slot. Hence patients booking to discuss a mental health concern will be given a 20-minute appointment. However, if a patient has not declared at the time of making the appointment that the appointment is to discuss a mental health concern, then the GP can send a message to reception to say that the consultation will take another 10 minutes and to keep any waiting patients informed of any delays. It is standard practice for our reception team to ask a patient the reason for their appointment at the time of booking an appointment to assist with planning the patient journey. There is no obligation on the patient to share information. While most patients declare their reasons for appointment some say it is “private” The Practice have agreed to book a review with the patient two weeks later where appropriate if medication has been commenced in relation to anxiety or depression symptoms. This should be then followed up with a medication review after 4 weeks where appropriate. Further appointments to be booked per advice from mental health practitioner, Talking Matters, counselling services or at patient request. The practice also has the option of signposting patients to the Practice Mental Health Nurses, to follow these patients up, to again sign post them to appropriate services like for CBT and counselling (to be another person who patient can speak to), to review their risk and get back to GP if they need any safeguarding put in place, to request GP to review them earlier than 2 weeks review as required, to refer them to CRISIS team if their mental health deteriorated in interim period. In addition, the Clinical pharmacist is available to assist with medication review to again discuss side effects of medications, to again discuss the importance of taking them regularly. The Clinical Pharmacist plays a vital role in prescribing weekly medications or even daily medications in patients who are at risk of taking an overdose. We have cascaded the outcomes of the Significant Event Analysis to all clinical members of our Practice team, which includes the reception and administration teams to ensure that they book the appropriate duration for each appointment and to reassure patients awaiting a consultation that they will be seen.
Stretton Medical Centre Stretton Branch Surgery 5 Hatton Lane Stretton 43-45 Dudlow Green Road Warrington Appleton WA4 4NE Warrington WA4 5EQ
We will arrange a follow-up appointment for any patients that DNA (did not attend) their appointment, with an ACCURX text message or a call when unable to send ACCURX text message. If the Practice can be of any further assistance to the Coroner, please let us know. Kind regards
1. There was no Significant Event Meeting following Olivia’s death: The original information received from the hospital as notification of Death had limited information and detailed cause of death as cardiac arrest rather than apparent suicide. Therefore, at the time of Olivia’s death, a Significant Event Meeting was not carried out as the Practice awaited further information from the hospital report.
Stretton Medical Centre Stretton Branch Surgery 5 Hatton Lane Stretton 43-45 Dudlow Green Road Warrington Appleton WA4 4NE Warrington WA4 5EQ
A SEA was conducted on 2 January 2024. The Practice accepts that an SEA should have been performed sooner and prior to the inquest to ensure that learning from the death was identified as soon as possible and changes made to systems or practice where required. This was an oversight on our part, and the Practice would like to apologise for the delay. This learning is shared with all the clinicians in our practice and will be shared with clinicians in our primary care network for peer review. The Practice would like to reassure you that all patient deaths will be discussed at our monthly MDT meeting. We have revised our monthly Clinical Team Meeting template and every unexpected death will be discussed with a view to complete a Significant Event Analysis on them to share any learning. Where appropriate, the Significant Event Analysis of a death will be completed in a month, ready to discuss in the next monthly Clinical Team Meeting.
2. To ensure relevant information is shared with a patient when commencing an antidepressant, in accordance with relevant clinical guidelines. This includes a discussion about risks, in particular the risk of relapse when stopping a medication and the risk of increased self- harm ideation at the outset of treatment. As a result of the SEA on 2 January 2024, NICE Guidance (NG222 – Depression in adults: treatment and management) has been recirculated to all clinicians highlighting the need to appropriately discuss with patients any risks and in particular, the risk of relapse. Also, we shared a copy of the General Medical Council’s guidance on prescribing to doctors. We have implemented a system whereby whenever an antidepressant or an anti- anxiety medication is prescribed a note will be added to patient and pharmacist to confirm “please do not stop these medications without medical advice”. This note will show up on the medication box label. We have reminded all GPs that at the time of commencing an antidepressant, they should have a conversation with the patient mindful of the relevant clinical guidelines. The GP is then to book a follow up review with the patient. We have included this reminder in new starters and locum induction pack to ensure they act accordingly.
Stretton Medical Centre Stretton Branch Surgery 5 Hatton Lane Stretton 43-45 Dudlow Green Road Warrington Appleton WA4 4NE Warrington WA4 5EQ
To ensure risks are discussed with patients on anti-depressant medication, the Practice recognises that appointment times would need to be extended beyond the usual 10-minute slot. Hence patients booking to discuss a mental health concern will be given a 20-minute appointment. However, if a patient has not declared at the time of making the appointment that the appointment is to discuss a mental health concern, then the GP can send a message to reception to say that the consultation will take another 10 minutes and to keep any waiting patients informed of any delays. It is standard practice for our reception team to ask a patient the reason for their appointment at the time of booking an appointment to assist with planning the patient journey. There is no obligation on the patient to share information. While most patients declare their reasons for appointment some say it is “private” The Practice have agreed to book a review with the patient two weeks later where appropriate if medication has been commenced in relation to anxiety or depression symptoms. This should be then followed up with a medication review after 4 weeks where appropriate. Further appointments to be booked per advice from mental health practitioner, Talking Matters, counselling services or at patient request. The practice also has the option of signposting patients to the Practice Mental Health Nurses, to follow these patients up, to again sign post them to appropriate services like for CBT and counselling (to be another person who patient can speak to), to review their risk and get back to GP if they need any safeguarding put in place, to request GP to review them earlier than 2 weeks review as required, to refer them to CRISIS team if their mental health deteriorated in interim period. In addition, the Clinical pharmacist is available to assist with medication review to again discuss side effects of medications, to again discuss the importance of taking them regularly. The Clinical Pharmacist plays a vital role in prescribing weekly medications or even daily medications in patients who are at risk of taking an overdose. We have cascaded the outcomes of the Significant Event Analysis to all clinical members of our Practice team, which includes the reception and administration teams to ensure that they book the appropriate duration for each appointment and to reassure patients awaiting a consultation that they will be seen.
Stretton Medical Centre Stretton Branch Surgery 5 Hatton Lane Stretton 43-45 Dudlow Green Road Warrington Appleton WA4 4NE Warrington WA4 5EQ
We will arrange a follow-up appointment for any patients that DNA (did not attend) their appointment, with an ACCURX text message or a call when unable to send ACCURX text message. If the Practice can be of any further assistance to the Coroner, please let us know. Kind regards