Lee Adams

Dear Dr Morris Regulation 28 Report to Prevent Future Deaths - regarding the death of Mr Lee Derek Jamie Adams Thank you for asking us to comment on the matters of concern following the sad death of Mr Lee Derek Jamie Adams, who died on the 28th of July 2020. Our sincere condolences go to his family and friends given the difficult circumstances and the ongoing questions on how this could have been prevented. We will address the issues raised as requested in the hope that the response can help answer the concerns of the Coroner and Mr Adams’ loved ones. You have two matters of concern for GPs relating to this tragic death:
• GPs should be aware of the consequences, at relatively small doses, of excess propranolol ingestion; especially when there is no specific anti-dote and treatment is restricted to supportive measures only.
• GPs should be reminded to ask individuals about their gambling habits in the same way that they ask about smoking and alcohol. To give context to the family, The Royal College of General Practitioners works to improve patient care by encouraging the highest possible standards in general medicine practice by supporting members, setting standards, providing education and training, promoting research, advocating and representing the College and its 56,000 members. General Practitioners have a broad curriculum, and the College is responsible for the definitive educational framework for all doctors undertaking GP speciality training. There are 5 areas of capability aligned to the General Medical Council’s Generic Professional Capabilities Framework, and these are supported by twenty-two Clinical Topic Guides. Within the Mental Health Clinical Topic guide areas of a GP’s role include aspects relevant to Mr Adams’ care: Take account of psychosocial factors, including cultural background, bereavement, unemployment, relationship problems, alcohol and substance misuse, and gambling and Assess risk to make the patient’s safety and the safety of yourself and others a priority. Be aware that risk assessment is important but that there are no validated scales that predict suicide Royal College of General Practitioners 30 Euston Square, London, NW1 2FB Tel: 020 3188 7400 | info@rcgp.org.uk | rcgp.org.uk Registered Charity Number 223106 | Patron: His Majesty King Charles III

[Page 2] This risk assessment includes the comprehensive approach of reviewing the level of risk of existing medications for both mental and physical health and their toxicity in overdose. The RCGP has been aware of the risks of Propranolol toxicity and responded to the HSSIB safety investigation to produce a ‘5 minutes to change your practice’ learning resource for GP members on the risks associated with prescribing Propranolol. I have not been provided with information regarding any risk assessments or consultations with the GP in Mr Adams’ care. Unfortunately, there is no information provided on where Mr Adams’ Propranolol supply was sourced, indicating an element of self-harm risk beyond what can be controlled from medication issued by a GP Practice. Awareness of self-harm thoughts or plans allow the GP an opportunity to reduce the amounts of harmful medications supplied as part of an initial risk reduction strategy, alongside additional mental health support, with the aim of suicide prevention. In addition to the GP curriculum, the RCGP Gambling Harms Hub is available for our members which encourages our members to complete the elearning course and webinar to be eligible to become a Gambling Harms accredited practice, with an established practice lead who is sent a staff training research pack that is intended for sharing with the practice team. Gambling Harms Accreditation:
• Shows enhanced commitment to improving health outcomes for patients experiencing gambling harms
• Sharing key learning points from learning with the wider practice team
• Reducing stigma by broaching gambling in consultations, where relevant
• Signposting patients to support, where needed
• Displaying resources in the waiting room and public areas This helps to demonstrate how significantly the College perceives the harms of gambling and associated behaviours that impact on patients and families. Once again, our condolences go to Mr Adams’ family and friends. I hope the comments provide a full picture of where the RCGP can influence the prevention of future deaths within training and continuing professional development.