Foxhayes Surgery GP Practice
Action Planned
AI-generated response summary
• The practice reviewed David's medical records and the actions taken by its medical team. • The practice will formalise referral processes and implement protocols to ensure follow-up by clinicians and the administration team. • The Practice Manager has enrolled in a Patient Safety Incidence Response Framework Course, and the practice is due to hold a significant event analysis in July.
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Dear Graham
RE: David Paul Joyce Address: 52 King Arthurs Road, Exeter, EX4 9BH DOB: 12 Feb 1990 NHS Number: 472 813 7600 Date of Death: 31 Aug 2023 Mr Joyce spoke to myself at Foxhayes Surgery on the 16th May 2023 having separated from his partner approximately a month earlier. This had affected David’s mood he reported that he was struggling, lacking motivation and struggling to leave the house. He hadn’t been to work and had taken the previous 7 nights off. He had been spending time with his friends but was struggling to pick himself back up. David had a history of diagnosis with dissociative disorder dating back to 2018 but no episodes of any mental health problems in the 5 years to his phone call on the 16th May. I had a long conversation with David that morning we talked about benefits and pitfalls of sick notes and the best methods to get himself back on track. We talked about aiming to return to work, spending time outdoors, visiting friends and doing some form of exercise. I discussed that a sick note may lead to
GPs
Dr Carl
The Foxhayes Surgery 117 Exwick Road, Exeter, EX4 2BH
E: foxhayes.prescriptions@nhs.net
a further deterioration in David’s mental health and agreed not to sign him off. I asked David to get back in touch with the practice should he not be able to turn things around. We would not typically refer an individual onto secondary or tertiary services presenting initially who is experiencing difficult life events. We speak to a very large number of patients who are struggling with life events including separation from partners that typically need time to resolve. Patients need to feel heard, understood and supported and I think we have a duty to offer appropriate pragmatic advice to patients on managing difficult life events. We always safety net at the end of our consultations and discuss appropriate follow up and additional support should the individuals not be able to keep on top of their symptoms and problems. David was seen on the 23rd of June in the Emergency Department of the Royal Devon & Exeter Hospital following a possible paracetamol overdose. David was also reviewed on the same day 23rd June whilst in Police custody by a Senior Mental Health Practitioner working for the Devon Liason and Diversion Service. He was reported by to be suffering from low mood. She gave him a support plan listing local sources of support. She did note report or refer him to the community Mental Health team or secondary Care Services. David contacted the surgery by econsult at 13:30 on the 26th June he was called back at 16:00 that day by plan after talking to David was to represcribe the Quetiapine which he found useful but had stopped taking this since his move to Exeter. She also agreed she would contact the Mental Health Practitioner who had reviewed David at the weekend to discuss a referral to the Mental Health Team. She provided him with contact numbers for The Moorings who are able to provide urgent counselling, Access & First Response Team and the Samaritans. Unfortunately, there is no follow up with regard to
GPs
Dr Carl
The Foxhayes Surgery 117 Exwick Road, Exeter, EX4 2BH
E: foxhayes.prescriptions@nhs.net
attempts to contact the Mental Health Team. I am unable from the medical records to ascertain whether she managed this or not. David contacted the Access & First Response Service on the 6th August during that consultation he reported that he had no thoughts of harm to himself or others. He was sent resources for self-care that he would look through with his sister. He was given advice about healthier activities going forward to help him get over his recent separation. David was next assessed by the Mental Health Team following his detainment on a 136 Section on the 22nd August. He was seen by , Consultant Psychiatrist and
Independant Registered Medical Practitioner and , Approved Mental Health Professional on the 23rd August. The outcome of this meeting was that David was not detained he was discharged back into the community, and he agreed to work with the Home Treatment Team, he was referred to Together to support his current alcohol consumption and breathing space to look at his financial issues. David’s case was opened by the Home Treatment Team on the 24th August. David contacted Foxhayes Surgery at 17:45 on 24th August following his review by the Home Treatment Team. He felt that he needed an urgent medical review as his Quetiapine was not helping. was not comfortable changing his dose of Quetiapine as he was under the specialist care for this and had seen his consultant psychiatrist the day before and the Home Treatment Team earlier that day. He had a pending follow up appointment on the 26th August with the Home Treatment Team. A prescription for his current and ongoing dose of Quetiapine was sent to the pharmacy on the 25th August by . I believe it would be unusual for a GP to carry out a medication change for a complex mental health patient who was reviewed less than 24 hours earlier by a Consultant Psychiatrist and the same day by the specialist Mental Health Home Treatment Team. Any changes
GPs
Dr Carl
The Foxhayes Surgery 117 Exwick Road, Exeter, EX4 2BH
E: foxhayes.prescriptions@nhs.net
made would I’m sure would be questioned by coroners in the future were it felt these changes may have been implicated in an episode of self-harm or suicide. Enquiring why the GP felt more experienced or qualified to make changes not deemed appropriate by a consultant less than 24 hours earlier. Having closely reviewed the medical records for David I sat down with the medical team at the practice to review his medical records and actions by the individual doctors and the practice . The consensus was the practice should have been more proactive on the 26th June when David represented making a formal referral to the Community Mental Health Team and possibly the CRISIS Team for urgent support given how David’s mental health had deteriorated in the 5 weeks prior to review. attempt to call and speak to following her review of David whilst in Police custody clearly caused a breakdown in the formal referral process for David at that time. However, had , (a Senior Mental Health Practitioner) felt that David needed support from the Mental Health Team whom she works for I would have expected her to make that referral when she saw him on the 24th June. The practice felt there needs to be improved lines of communication between Primary Care and the Community Mental Health Team including consultants and Home Treatment Team for a patient who is currently under their care. Usually, the Mental Health Team take ownership and responsibility for prescribing and dose changes for anti-psychotic medication as they had for David. It would be unusual for a General Practitioner to then step in and alter the dose or medication whilst under the expert care of Consultant Psychiatrists (who they saw the day prior and chose not to make any medication changes and was also reviewed that day by the Home Treatment Team who also decided not to make any medication changes). It seemed there was disjointed
GPs
Dr Carl
The Foxhayes Surgery 117 Exwick Road, Exeter, EX4 2BH E: foxhayes.prescriptions@nhs.net
support from different arms of Devon Partnership Trust with no joined up or cohesive care for David provided by Devon Partnership Trust. The practice has reviewed and looked at how we support, refer on and liase with Mental Health Team for high-risk patients presenting with psychotic symptoms. The practice recognises that the referral approach on the 26th June was reliant upon return phone calls or emails from the Mental Health Team and as these did not happen the referral intention was lost. It is important that these processes are formalised, and protocols put in place to ensure follow up by clinicians and the admin administration team at the practice to ensure this does not happen again. The Practice Manager has enrolled on a Patient Safety Incidence Response Framework Course so that we can review our practice against the updated patient safety incident response standards and understand how to respond proportionally to patient safety incidents, explore and understand the patient safety incident profiles. The practice is due to hold a significant event analysis in July of this year to review David’s case and explore ways to ensure that the practice is maximally supporting vulnerable patients such as David.
RE: David Paul Joyce Address: 52 King Arthurs Road, Exeter, EX4 9BH DOB: 12 Feb 1990 NHS Number: 472 813 7600 Date of Death: 31 Aug 2023 Mr Joyce spoke to myself at Foxhayes Surgery on the 16th May 2023 having separated from his partner approximately a month earlier. This had affected David’s mood he reported that he was struggling, lacking motivation and struggling to leave the house. He hadn’t been to work and had taken the previous 7 nights off. He had been spending time with his friends but was struggling to pick himself back up. David had a history of diagnosis with dissociative disorder dating back to 2018 but no episodes of any mental health problems in the 5 years to his phone call on the 16th May. I had a long conversation with David that morning we talked about benefits and pitfalls of sick notes and the best methods to get himself back on track. We talked about aiming to return to work, spending time outdoors, visiting friends and doing some form of exercise. I discussed that a sick note may lead to
GPs
Dr Carl
The Foxhayes Surgery 117 Exwick Road, Exeter, EX4 2BH
E: foxhayes.prescriptions@nhs.net
a further deterioration in David’s mental health and agreed not to sign him off. I asked David to get back in touch with the practice should he not be able to turn things around. We would not typically refer an individual onto secondary or tertiary services presenting initially who is experiencing difficult life events. We speak to a very large number of patients who are struggling with life events including separation from partners that typically need time to resolve. Patients need to feel heard, understood and supported and I think we have a duty to offer appropriate pragmatic advice to patients on managing difficult life events. We always safety net at the end of our consultations and discuss appropriate follow up and additional support should the individuals not be able to keep on top of their symptoms and problems. David was seen on the 23rd of June in the Emergency Department of the Royal Devon & Exeter Hospital following a possible paracetamol overdose. David was also reviewed on the same day 23rd June whilst in Police custody by a Senior Mental Health Practitioner working for the Devon Liason and Diversion Service. He was reported by to be suffering from low mood. She gave him a support plan listing local sources of support. She did note report or refer him to the community Mental Health team or secondary Care Services. David contacted the surgery by econsult at 13:30 on the 26th June he was called back at 16:00 that day by plan after talking to David was to represcribe the Quetiapine which he found useful but had stopped taking this since his move to Exeter. She also agreed she would contact the Mental Health Practitioner who had reviewed David at the weekend to discuss a referral to the Mental Health Team. She provided him with contact numbers for The Moorings who are able to provide urgent counselling, Access & First Response Team and the Samaritans. Unfortunately, there is no follow up with regard to
GPs
Dr Carl
The Foxhayes Surgery 117 Exwick Road, Exeter, EX4 2BH
E: foxhayes.prescriptions@nhs.net
attempts to contact the Mental Health Team. I am unable from the medical records to ascertain whether she managed this or not. David contacted the Access & First Response Service on the 6th August during that consultation he reported that he had no thoughts of harm to himself or others. He was sent resources for self-care that he would look through with his sister. He was given advice about healthier activities going forward to help him get over his recent separation. David was next assessed by the Mental Health Team following his detainment on a 136 Section on the 22nd August. He was seen by , Consultant Psychiatrist and
Independant Registered Medical Practitioner and , Approved Mental Health Professional on the 23rd August. The outcome of this meeting was that David was not detained he was discharged back into the community, and he agreed to work with the Home Treatment Team, he was referred to Together to support his current alcohol consumption and breathing space to look at his financial issues. David’s case was opened by the Home Treatment Team on the 24th August. David contacted Foxhayes Surgery at 17:45 on 24th August following his review by the Home Treatment Team. He felt that he needed an urgent medical review as his Quetiapine was not helping. was not comfortable changing his dose of Quetiapine as he was under the specialist care for this and had seen his consultant psychiatrist the day before and the Home Treatment Team earlier that day. He had a pending follow up appointment on the 26th August with the Home Treatment Team. A prescription for his current and ongoing dose of Quetiapine was sent to the pharmacy on the 25th August by . I believe it would be unusual for a GP to carry out a medication change for a complex mental health patient who was reviewed less than 24 hours earlier by a Consultant Psychiatrist and the same day by the specialist Mental Health Home Treatment Team. Any changes
GPs
Dr Carl
The Foxhayes Surgery 117 Exwick Road, Exeter, EX4 2BH
E: foxhayes.prescriptions@nhs.net
made would I’m sure would be questioned by coroners in the future were it felt these changes may have been implicated in an episode of self-harm or suicide. Enquiring why the GP felt more experienced or qualified to make changes not deemed appropriate by a consultant less than 24 hours earlier. Having closely reviewed the medical records for David I sat down with the medical team at the practice to review his medical records and actions by the individual doctors and the practice . The consensus was the practice should have been more proactive on the 26th June when David represented making a formal referral to the Community Mental Health Team and possibly the CRISIS Team for urgent support given how David’s mental health had deteriorated in the 5 weeks prior to review. attempt to call and speak to following her review of David whilst in Police custody clearly caused a breakdown in the formal referral process for David at that time. However, had , (a Senior Mental Health Practitioner) felt that David needed support from the Mental Health Team whom she works for I would have expected her to make that referral when she saw him on the 24th June. The practice felt there needs to be improved lines of communication between Primary Care and the Community Mental Health Team including consultants and Home Treatment Team for a patient who is currently under their care. Usually, the Mental Health Team take ownership and responsibility for prescribing and dose changes for anti-psychotic medication as they had for David. It would be unusual for a General Practitioner to then step in and alter the dose or medication whilst under the expert care of Consultant Psychiatrists (who they saw the day prior and chose not to make any medication changes and was also reviewed that day by the Home Treatment Team who also decided not to make any medication changes). It seemed there was disjointed
GPs
Dr Carl
The Foxhayes Surgery 117 Exwick Road, Exeter, EX4 2BH E: foxhayes.prescriptions@nhs.net
support from different arms of Devon Partnership Trust with no joined up or cohesive care for David provided by Devon Partnership Trust. The practice has reviewed and looked at how we support, refer on and liase with Mental Health Team for high-risk patients presenting with psychotic symptoms. The practice recognises that the referral approach on the 26th June was reliant upon return phone calls or emails from the Mental Health Team and as these did not happen the referral intention was lost. It is important that these processes are formalised, and protocols put in place to ensure follow up by clinicians and the admin administration team at the practice to ensure this does not happen again. The Practice Manager has enrolled on a Patient Safety Incidence Response Framework Course so that we can review our practice against the updated patient safety incident response standards and understand how to respond proportionally to patient safety incidents, explore and understand the patient safety incident profiles. The practice is due to hold a significant event analysis in July of this year to review David’s case and explore ways to ensure that the practice is maximally supporting vulnerable patients such as David.