Source · Prevention of Future Deaths

George Cheese

Ref: 2017-0179 Date: 6 Jun 2017 Coroner: Peter Bedford Area: Berkshire Responses identified: 1 / 1 View PDF

A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system or "flag" in their notes to limit repeat prescriptions in such circumstances.

Date 6 Jun 2017

56-day deadline 29 Sep 2017 est.

Responses identified 1 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system or "flag" in their notes to limit repeat prescriptions in such circumstances.

View full coroner's concerns

(1) While the evidence at the Inquest dealt with the various matters ongoing in Mr Cheese’s life, I also heard evidence of the care and treatment that he received from his GP surgery. One of the doctors at the surgery, gave live evidence at the Inquest.

(2) Mr Cheese was prescribed Fluoxetine anti-depressant medication on the 3rd November 2014 by a treating GP, following admitting to fleeting suicidal thoughts. He was reviewed by on 14th January 2015 when Mr Cheese described daily episodes of intense low mood with suicidal thoughts which included taking an overdose. This led to a reference to the Mental Health Team. At an appointment with the Practice’s Nurse Practitioner on 3rd February, Mr Cheese was prescribed 112 tablets of Fluoxetine. In the course of her evidence, stated that the Nurse Practitioner was probably just repeating the same prescription that the previous Doctor had issued to Mr Cheese but that she, , would not have done that.

(3) also acknowledged, in the course of her evidence, that there was no “flag” on Mr Cheese’s notes to alert treating Clinicians within the GP Practise to limit the amount of medication provided to Mr Cheese in view of his history. She acknowledged that a flag, in such circumstances, was good practise.

(4) The concerns arising from the evidence are therefore the amount of medication prescribed to a patient who was known to be suffering from mental health issues and describing suicidal thoughts and a potential overdose and the fact that this was not being flagged to prevent large amounts of medication being provided to him as a matter of repeat prescription.

Responses

1 respondent

Woodley Centre Surgery Other

27 Jul 2017 PDF

Action Taken

The surgery introduced a policy requiring GPs only to issue repeat prescriptions and conduct depression reviews. They will also discuss the role of clinicians at a clinical meeting and arranged for a consultant psychiatrist to talk about management of mental health disorders. (AI summary)

View full response

Dear Mr Bedford, Thank Vou for your letter and report dated 6"h June requesting the surgerv' s response to the inquest of George Cheese about the number of your concerns raised at antidepressant tablets prescribed to him without adequate review. enclose a copy of our antidepressant prescribing policy; the result of discussions with partners which / hope will answer those concerns. my Shortly after George died the partners introduced the requirement for the issue of repeat prescriptions and depression reviews to be conducted by GPs only; receptionists are aware that patients with anxiety and depression cannot be seen by nurse practitioners This policy has been circulated to all our GPs and nurses/nurse practitioners. The addition of a or 'major alert' on the front screen of patient's record is the responsibility of the GP who initially assesses or reviews the patient should have concerns at time. This could include receiving a letter Talking Therapies expressing concern about aapettemcesucidalth thoughts_ have written up the role of the clinicians including the issue of 112 capsules of fluoxetine to George = on 2 occasions a5 a 'significant event' and will be discussing this at our next clinical meeting on Thursday 276 Analvsis of significant events is a requirement of the CQC (Care Quality Commission) inspection to July: that events that have been detrimental to patient care have been identified, discussed and demonstrate learnt with the aim of improving the quality of care: We have also arranged for lessons have been a consultant psychiatrist from the focal mental health team to talk about management of mental health disorders at our clinical meeting scheduled for Wednesday 23rd August. hope that these policy changes together with discussion and education will reduce the risk of overdose to patient in future. any

Report sections

Investigation and inquest

I conducted an Inquest into the death of Mr George Arthur Cheese that was heard at Reading Town Hall between the 23rd and 25th May 2017 inclusive. The conclusion of the Inquest was that Mr Cheese took his own life whilst suffering from a depressive disorder brought on by a series of life events. A full copy of the Narrative Conclusion is attached.

Circumstances of the death

Mr Cheese was an 18 year old young man who was found hanging in Woodland near his home address on 9th April 2015. He had a number of ongoing issues in his life including the potential loss of a career in the army; a fluctuating relationship with his girlfriend; an unsubstantiated concern that he might have a serious illness and he had been subject to upsetting treatment by his colleagues at work. He was under the care of his GP surgery and the local Mental Health Team who were treating him for anxiety and depression including prescribing anti-depressant medication.

Classification: OFFICIAL-SENSITIVE
-1-

Classification: OFFICIAL-SENSITIVE

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

Action should be taken

In my opinion urgent action should be taken to prevent future deaths in such circumstances and I believe your Surgery has the power to take such action.

Classification: OFFICIAL-SENSITIVE
-2-

Classification: OFFICIAL-SENSITIVE

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

Copies sent to

of Mr Cheese6th June 2017Peter J. Bedford Senior Coroner for BerkshireClassification: OFFICIALSENSITIVE

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Report details

Reference: 2017-0179
Date of report: 6 June 2017
Coroner: Peter Bedford
Coroner area: Berkshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 29 Sep 2017 (estimated).

Sent to

Woodley Centre Surgery

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.