Clare Cooper

Dear Dr Henderson Inquest into_the death of Miss Clare_Serena Anke Cooper RCGP response Thank you for your letter of 25 July addressed to] which has been passed t0 me. As Honorary Secretary of the College Council am the College Officer responsible for responding to Coroners' Regulation 28 Reports. was very sorry to hear of the death of Miss Cooper and the series of events leading up to it: set out below a brief description of the remit of the Royal College of General Practitioners and provide some detailed comments on the specific concerns you raise in your report: The role of_the College The Royal College of General Practitioners is a registered charity under Royal Charter and is the largest membership organisation in the United Kingdom solely for GPs Founded in 1952 , it has over 50,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline We are an independent professional body with enormous expertise in patient-centred generalist clinical care. Through our General Practice Foundation, established by the RCGP in 2009, we also maintain close links with other professionals working in General Practice, such as practice managers, practice nurses and physician assistants_ As well as running the postgraduate Membership examination (MRCGP) which is now required for doctors to qualify as GPs, the College also provides continuing professional development (CPD) for its members, and these continuing programmes are also available to non-members of the College: However, not all GPs are members of the College, and older GPs may never have joined. The General Medical Council holds the register of all who are considered able to practise as GPs, and it is to the GMC that revalidated doctors will be notified. Similarly, it is not for us to comment on the performance of any individual GP and the information set out below is solely to show you what we provide in the context of training and advice to our Members. RCGP Education and Training Currently all doctors wishing to follow a career in general practice in the UK are required to undergo a 3 year programme of vocational training for general practice, based on the College's GP Curriculum_ Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp.org uk Web WWw rcgp org uk Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106

(The curriculum forms the foundation for GP training and assessment across the UK, prior to taking the College's Membership Examination (MRCGP) and continues to be relevant to GPs throughout their career including preparation for revalidation) httpIIwWW rcgporg uklgp-training-and-examslgp curriculum-overview aspx The GP Curriculum sets out College expectations of the standard of care that a general practitioner should provide and will use references to the GP Curriculum as a basis for my response Comments on Coroner's concerns on the general practitioner_care provided to Miss Clare Cooper The underlying principle for a general practitioner's management of any patient should be one of "holistic care This is set out in the section of the GP Curriculum entitled "'the Consultation in Practice" where the following advice is set out: "As a GP you should:
6.4 Understand that consultations have a clinical, a psychological and a social component; with the relevance of each component varying from consultation to consultation (the 'triaxial' model)" give below detailed comments on the first six matters of concern you list in this particular case ,, ie those which directly relate to general practitioner care , setting aside your listed concerns 7 to 10 on which advice from hospital medicine will be more appropriate Poor GP documentation The College believes that sound recording systems and well organised record-systems are fundamental to good general practice and communications with fellow healthcare professionals outside the practice This expectation is out in the section of the GP Curriculum on A GP' http IwWW rcgporg uklgp-training-and-exams/~Imedia/Files/GP-training-and-exams/Curriculum 2012/RCGP-Curriculum-1-Being-a-GP ashx "As a GP you should_
1.2.3 Develop the clinical skills you need in history-taking, physical examination the use of ancillary tests for diagnosis" and "1.5.2 Develop your organisational skills for record-keeping, information management;, teamwork, running practice and auditing the quality of care' And again is highlighted in the section The Consultation in General Practice" where the GP is enjoined under criterion 1.6 to 'Effectively use patient records (electronic or paper) during the consultation to facilitate high-quality patient care and in 1.10 to "keep accurate, legible and contemporaneous records' The qualities required of the GP in information gathering and recording its importance for good patient care are further spelled out under the section Patient Safety and the Quality of Care" of the GP Curriculum: http IIwWW rcgp org Uklgp-training-and-exams/~Imedia/FilesIGP-training-and-examsICurriculum_ 2012/RCGP_Curriculum-2-02-Patient-Safety-and-Quality-Of-Care ashx refers: 'As a GP, you should: "Demonstrate an understanding of the connection between good data entry improved patient health outcomes
1.14 Demonstrate how to use information management and technology (IM&T) to share information and co-ordinate patient care with other health professionals
1.15 Demonstrate an understanding of the need for information recorded in the practice clinical system to be fit for sharing with different health professionals in different organisations Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp org.uk Web WWw_rcgp.org uk Patron: Royal Highness the Duke of Edinburgh Registered charity number 223106 set 'Being and and and His

1.16 Demonstrate how to use NHS electronic booking systems to tailor healthcare provision to the needs of the individual patient
1.17 Demonstrate the use of the practice's computer system to improve the quality and usefulness of the medical record, e.g: through audit
1.18 Demonstrate effective use of interagency systems such as pathology links and GP_GP record transfer"
2. "Lack of evidence ofa robust assessment of_presenting signs and symptoms_ The following section of the GP Curriculum provides advice on the diagnosis of metabolic disorders http IlwWW Icgporg uklgp-training-and-examsk~ImedialFilesIGP-training-and-exams/Curriculum 2012/RCGP-Curriculum-3-17-Metabolic-Problems ashx The Messages given on page 3 of this section are particularly relevant in this case: "As a general practitioner(GP)you should have an understanding of how common endocrine or metabolic disorders such as diabetes mellitus, thyroid or reproductive disorders can present: You must also be aware of rarer and important disorders such as Addison's disease, which can be potentially life-threatening if missed Biochemical tests can be diagnostic often necessary for monitoring metabolic and endocrine diseases.so it is important for GPs to know which tests are useful in a primary care setting how to interpret these tests and understand their limitations" "Lack of GP routine vital sign monitoring eg heart rate_blood pressure and weight measurement: Noestablished system for recognition_assessment and management of electrolyte abnormalities within the_GP Practice
5. Lack of understanding of the_underlying causes of hyponatraemia Guidance on the use of routine tests in general practice is provided on page 6 of the Section on "Primary Care Management" a GP you should_
1.6 Understand the use and main limitations of tests commonly used in primary care to investigate and monitor metabolic or endocrine disease, e.g: fasting blood glucose, HbAIc, urinalysis for glucose and protein, urine albumin: creatinine ratio, 'near patient testing (point of care testing)for capillary glucose, lipid profile and thyroid function tests, and uric acid tests" Insufficiently detailed referral letter to EDS Guidance on referral to secondary care is provided in the following sections. Being a GP http:LLwWW rcgp org_uklgp-training-and-exams [media/FilesIGP-training-and-exams[Curriculum 2012[RCGP-Curriculum-1-Being-a-GP ashx This section advises the general practitioner at all times to: "1.3 Co-ordinate care with other professionals in primary care and with other specialists" And spells this out as follows: This means that as a GP you should:
1.3.2 Understand the importance of excellent communication with patients and staff for effective teamwork
1.4.2 Understand the processes of referral into secondary care and other care pathways Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgporg.uk Web WWw rcgp.org uk Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106 Key and and "As

1.4.3 Manage the interface between primary and secondary care, including unscheduled care, accurate sharing of information on medicines communication with other professionals
1.5 Make available to your patients the appropriate services within the healthcare system This means that as a GP you should:
1.5.2 Develop your organisational skills for record-keeping, information management; teamwork, running a practice and auditing the quality of care" (You will see that in this section, the need for excellent communication based on full, accurate records is again emphasised ) Guidance on the writing of referral letters is provided in the section The General Practice Consultation in Practice" http Iwww_gponline com/rcgp-curriculumlthe-general-practice-consultation hope you find these comments helpful.

Dear Dr Henderson, Re: Miss Clare Cooper (Regulation 28 Report Action prevent Future Deaths): Thank you for your letter dated 25.7.2014. have been aware of this case since the family approached me to the Coroner's hearing; seeking to instruct me in a expert capacity regarding their daughter' s tragic death: At that stage , indicated a conflict of interest, given my leadership of the Royal College of Psychiatrists Eating Disorder Section, but do therefore have a longitudinal knowledge of the case. have already responded to the family' s own correspondence with myself, and attach this for your interest: The issues raised in your report address the need for better EDS proformas in the triaging of patients with eating disorders On behalf of the Royal College of Psychiatrists, agree with this entirely. However would add two additional points. First; the Royal College of Psychiatrists is generally concerned about risk assessment in psychiatry, over ad above eating disorders, with undue reliance on risk assessment proformas_ This is reflected in the Alderdice and the Kennedy reports on suicide and homicide prevention, with services increasingly using risk assessment proformas as & type of 'checklist necessary but not sufficient in the evaluation of risk Proformas provide helpful aide memoire, but are insufficient to allow the detection of relatively rare differential diagnoses_ Thus, as well as decent proformas, we require eating disorder specialists with adequate medical training: As a Faculty, we assert the need for better standards of eating disorder specialism , and have submitted curriculum to the GMC for training standards to be met before doctor is recognised as a specialist in eating disorders_ istered office: 21 Prescot Street, London, El SBB Tel: +44 (0)20 7235 2351 +44 (0120 7977 6655 Fax: +44 (0120 3701 2761 WWw rcpsvch.acuk Charity registration number: 228636 NO HEALTH WITHOUT MENTAL HEALTH prior Regi

We also have concems over the heterogeneity of outpatient services across the UK have established standards for inpatient services (available at: http IIww rcpsych ac uklworkinpsychiatry/qualityimprovement aspx)_ but outpatient services are based on local commissioning decisions For example, we are aware of some outpatient services with limited medical input The specific issue of robust EDS proformas is best tackled through the MARSIPAN Guidelines of the Royal College of Physicians and the Royal College of Psychiatrists, which address physical risk monitoring in eating disorders: co-authored the original guideline, and have CO- authored a revised guideline , but the lead in this has been whose expertise in risk assessment in eating disorders is well recognised. As you will see in my correspondence with the family, will ask to consider how best to disseminate robust EDS proformas across the UK health economy, probably best tethered to the launch of the revised MARSIPAN Guidelines, which is forthcoming It would be within the remit of MARSIPAN to provide 'a national protocol for assessing patients seriously ill with an eating disorder with possibility_of_detecting individuals with an organic basis for the condition' also understand that has knowledge of this specific case. am likely to step down as Chair of the Royal College of Psychiatrists Eating Disorder Section before the end of the year, though attend the next Executive Committee Meeting in the autumn will raise the issues within your letter at that meeting; but wished to correspond prior to the next meeting,given the deadline for a response of 56 days Thereafter, the administrator of the committee at The Royal College of Psychiatrists, 21 Prescot Street, London E1 8BB. Kind regards, Consultant Psychiatrist will