Source · Prevention of Future Deaths
Margaret Pegnall
A GP practice had a vague domestic abuse flowchart focused on depression, lacked a specific domestic abuse questionnaire, and had no system for escalating urgent patient calls.
Date
31 Dec 2015
56-day deadline
2 Mar 2016
Responses identified
0 of 1
Coroner's concerns
A GP practice had a vague domestic abuse flowchart focused on depression, lacked a specific domestic abuse questionnaire, and had no system for escalating urgent patient calls.
View full coroner's concerns
In lhe circumstances it is my statutory duty to report to you: (1) Mrs Pegnall went to see her GP on 19 January 12 March 2015 regarding difficulties she was having with her husband_ The GP asked questions with regard to depression using a Flowchart atlached to the Surgery's on Domestic Violence and Abuse. Mrs Pegnall wrote letters to the Practice referring to her interaction with the Police. Mrs Pegnall telephoned the Practice on the of her death asking to speak to particular GP who was absent requesting "intervention" (2) The Flowchart for Responding to Domestic Abuse is vague and uses an Assessment of Risk pertaining lo depression and not to the risk of abuse (3) There is no Questionnaire specific to Domestic Abuse to assist in recognising signs of abuse and standardising the Surgery's GPs' response to concerns raised (4) There was no method available to members of staff to recognise when a patient's call should be escalated and dealt with immediately.
Report sections
Investigation and inquest
On 19 May 2015 commenced an investigation into the death of MARGARET CAROLE ANN PEGNALL, AGE 69 YEARS. The investigation concluded at the end of the inquest on 22 December 2015. The conclusion of the inquest was Medical Cause of Death: 1a) Multiple Injuries the Conclusion: Suicide
Circumstances of the death
On 18 May 2015 Mrs Pegnall slepped into the path ofa train at Stracey Arms, Norwich. She turned her back on the train and raised her arms_ She was hit by the train and died as a result of her injuries.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action_ and and Policy day
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Report details
- Date of report
- 31 December 2015
- Coroner
- Jacqueline Lake
- Coroner area
- Norfolk
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Mar 2016.
Sent to
- Old Catton Medical Practice