Roundwell Medical Centre
Other
Action Taken
Roundwell Medical Centre has implemented several immediate actions regarding patients on addictive medications including assigning a single GP where possible, detailing clinical plans, adding read codes for easy identification, and a six-month medication review. They will design a bespoke "Addictive Medication Review" template within 3 months and include patients on weekly medication in risk profiling. (AI summary)
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Dear Coroner Re: Katheryn Louise Sawyer Inquest Regulation 28 refer to the Regulation 28 form issued to following the inquest into the death of Katheryn Louise Sawyer; held on 8" April 2014. The circumstances around the death and the Regulation 28 form were discussed at our Clinical Governance meeting held on 24th April 2014. Six of the GPs were present together with members of the nurse team and the Practice Manager and Assistant Practice Manager: The following actions were agreed in order to prevent the circumstances around Mrs Sawyer's death happening again within the practice.
1. For all patients on addictive medication will see only one GP , where possible, to provide for continuity of care for that patient Action immediate 2 For patients being put on addictive medication, the GP will ensure that the clinical plan management is fully detailed in the patients' medical records. Action immediate 3 All patients who receive their medication weekly are to have a read code added to their medical record in order that are easily identified, monitored and audited. Action read code immediate, audit to be carried out within one month; 4_ All patients on long term medication of Benzodiazepines and Opiates will have a six month medication review which will document the clinical planl management discussed with the patient_. Action immediate 5_ Patients referred to Norwich Recovery Partnership to have a read code added in order that are easily identified, monitored and audited, Action immediate PCRIN Amee Incecnzz 2014 Way 2nd they they
6_ A bespoke "Addictive Medication Review" template to be designed to ensure that all reviews are documented and completed correctly. Action within 3 months All patients on weekly medication to be included in the risk profiling for the Unplanned Avoidable Admissions Directed Enhanced Service, which will be reviewed on a regular basis. Action within 3 months 8 Where a patient is requesting a prescription for an addictive medication earlier than it is due, the administration team will add a note to the patient records and send an internal task to the relevant GP to consider appropriate action eg GP will contact patient and ask them to come to the surgery for a face to face appointment: Action immediate 9 An audit to be completed on all patients being prescribed methadone. Action within one month
10.All methadone maintenance medications need to be read coded and linked to "problem' on the patients' medical records. prescription added by an outside agency eg Norfolk Recovery Partnership, needs to be noted on patients records_ Action immediate
11. Concerns were noted for those patients on addictive medication who failed to attend appointments. Agreed a regular search would be completed to identify patients and relevant action to be taken: Action regular monthly search: If you require any further information or some clarification on the actions noted above please do not hesitate to contact me.
1. For all patients on addictive medication will see only one GP , where possible, to provide for continuity of care for that patient Action immediate 2 For patients being put on addictive medication, the GP will ensure that the clinical plan management is fully detailed in the patients' medical records. Action immediate 3 All patients who receive their medication weekly are to have a read code added to their medical record in order that are easily identified, monitored and audited. Action read code immediate, audit to be carried out within one month; 4_ All patients on long term medication of Benzodiazepines and Opiates will have a six month medication review which will document the clinical planl management discussed with the patient_. Action immediate 5_ Patients referred to Norwich Recovery Partnership to have a read code added in order that are easily identified, monitored and audited, Action immediate PCRIN Amee Incecnzz 2014 Way 2nd they they
6_ A bespoke "Addictive Medication Review" template to be designed to ensure that all reviews are documented and completed correctly. Action within 3 months All patients on weekly medication to be included in the risk profiling for the Unplanned Avoidable Admissions Directed Enhanced Service, which will be reviewed on a regular basis. Action within 3 months 8 Where a patient is requesting a prescription for an addictive medication earlier than it is due, the administration team will add a note to the patient records and send an internal task to the relevant GP to consider appropriate action eg GP will contact patient and ask them to come to the surgery for a face to face appointment: Action immediate 9 An audit to be completed on all patients being prescribed methadone. Action within one month
10.All methadone maintenance medications need to be read coded and linked to "problem' on the patients' medical records. prescription added by an outside agency eg Norfolk Recovery Partnership, needs to be noted on patients records_ Action immediate
11. Concerns were noted for those patients on addictive medication who failed to attend appointments. Agreed a regular search would be completed to identify patients and relevant action to be taken: Action regular monthly search: If you require any further information or some clarification on the actions noted above please do not hesitate to contact me.