Pauline Meredith

Browning Street Surgery,
10 Browning Street,
Stafford
ST16 3AT

Mrs M J Jones
HM Assistant Coroner,
Coroner’s Office,
No1 Staffordshire Place,
Stafford
ST16 2LP

Response to Prevent Future Deaths Report: Miss Pauline Meredith

13.3.2014

Dear Mrs Jones,

Thank you for sending the Prevent Future Deaths Report dated 10th January. The practice has taken
your  concerns  very  seriously  and  I  am  writing  this  response  on  behalf  of  the  practice.  Since  the
Coroner’s Inquest on 9th January the partners and practice manager have held a meeting in which we
discussed  the  report  as  well  as  the  events  leading  up  to  Miss  Meredith’s  death  and  whether  any
more could have been done to prevent her death and possible future deaths.

As  you have acknowledged in your report, Miss Meredith was a chaotic and vulnerable adult who
had  a  long  history  of  behavioural  and  mental  health  problems.  She  had  a  number  of  emotional
traumas and life events in the past which led to her coping with stress with angry outbursts, alcohol
binges, self-harm and overdoses. She also suffered with chronic pain from a compressed fracture of
lumbar  vertebra  as  well  as  abdominal  pains  from  adhesions  following  her  appendix  abscess  and
subsequent operations. At the time of her death she had additional painful orthopaedic problems -
she  was  being  followed  up  by  orthopaedic  surgeons  regarding  a  fracture  of  her  metatarsal  in  her
foot and a fracture of her elbow. She had brief episodes of support from mental health and alcohol
services  through  the  years  but  her  engagement  with  this  was  usually  short-lived.  The  practice  has
responded  to  a  significant  challenge  in  attending  to  her  multiple  physical  and  psychological  health
needs over the last 15 years. Miss Meredith died from a self-administered but accidental overdose
of prescription drugs.

In considering the context of Miss Meredith’s care, I would wish to point out that I have significant
experience in mental health. I was Clinical Champion for Mental Health and Learning Disability for
South  Staffordshire  PCT  from  2008  to  2010  until  funding  was  withdrawn  for  all  Clinical  Champion
roles. As a GP with Special Interest in Addictions, I have additional expertise in managing addiction,
and as a Trainer for the Royal College of General Practitioners for the ‘Certificate in Management of
Substance  Misuse  in  General  Practice’  as  well  as  ‘Managing  Alcohol  Dependence  in  Primary  Care’
course. I have expertise in managing opiate dependency having treated addiction patients in General
Practice  for  over  15 years.  I  have  delivered  talks  and  presentations  to  health  care  commissioners,
consultants, GPs as well as trainee GPs on substance misuse and mental health. I have also kept my
skills updated by attending regular conferences over the past 15 years on Substance Misuse, Alcohol
Misuse, as well as conferences on ‘Addiction to Prescribed and Over-the-Counter Medication’.
You  have  raised  specific  concerns  in  the  Prevent  Future  Deaths  Report  and  I  will  address  each  of
these.

1

 1. Amount of medication prescribed and formal medication review
You have expressed concern about the amount of medication prescribed over the years and the lack
of a formal medication review process.

Before  her  death,  Miss  Meredith  was  prescribed  a  weekly  prescription  for  9  items  (including
Morphine  Sulphate  Tablets  (Slow  Release)  10mg,  lorazepam  and  tramadol)  and  a  monthly
prescription for an additional 7 items.

I  would  wish  to  reassure  you  that  there  is  indeed  a  formal  medication  review  process  used  at  the
practice.  The  medication  review  system  is  computer  based.  The  computer  automatically  initiates  a
demand  for  review  of  medication  for  each  patient  who  has  repeat  medications.  This  is  usually
annually  but  can  occur  more  frequently  depending  on  the  monitoring  requirements  stipulated  by
the prescribing doctor. The computer also places limits on the number of repeats that can be issued
without re-authorisation of the repeat medication by  a doctor. The review of repeat medication is
usually based on clinical information contained in annual health checks or from consultations at the
practice or from a dedicated review of repeat medication with the patient.

The  Medication  Review  would  authorise  medication  for  the  next  12  months  for  straight  forward
patients on straight forward medication. Not only were these automatic medication review checks in
place for Miss Meredith but additional, special arrangements were put in place for Miss Meredith, to
ensure that additional monitoring of her prescribing occurred.  The special monitoring was thought
necessary  since  2000  because  Miss  Meredith  had  a  history  of  deliberate  overdose.  Therefore  the
practice had arranged it so that Miss Meredith was on prescriptions written every 7 days instead of
every  month,  in  order  to  limit  her  access  to  medication,  as  well  as  weekly  appointments  with  a
doctor  to  check  on  her  mental  state  and  provide  additional    support.  She  was  not  able  to  request
repeat prescriptions without seeing a GP or at least contacting the practice if she could not attend
an  appointment.  She  had  to  see  a  doctor  in  order  to  obtain  a  prescription.  Hence  her  medication
was controlled by the frequent appointments at the surgery and this allowed for careful monitoring
of the medications prescribed.

The most recent documented medication review prior to Miss Meredith’s death on 30th August 2013
occurred on 24th June 2013. This involved a discussion with the patient and myself (the prescribing
GP).  In  addition,  in  the  8  months  from  January  2013,  Pauline  had  received  32  face  to  face
consultations, 9 telephone consultations and 1 home visit (related to diarrhoea). She had seen other
GPs  8  times  including  3  other  partners  and  the  Nurse  Practitioner.  Each  of  these  frequent
consultations meant that the consulting GP could discuss medication and check on her well-being.

Over  her  many  consultations,  I  have  discussed  with  her  a  number  of  safety  aspects  of  her
medication,  including:  1)  the  addictive  nature  of  benzodiazepines,  2)  the  use  of  propranolol  in
asthma,  3)  use  of  zopiclone  at  a  level  outside  the  licensed  dose  4)  the  potential  effects  of  binging
alcohol on her seizures as well as on her medication. One such consultation occurred on 11/02/2013
when  unusually  for  Miss  Meredith,  she  had  overused  her  lorazepam.  I  advised  her  that  this  was
unacceptable  due  to  the  addictive  nature  of  this  drug  and  the  risks  she  was  taking  by  not  being
compliant with her prescribed dosage. The clinical records show that Miss Meredith was being seen
every week and her medication was not simply handed over without a discussion about the risks and
benefits. She was fully aware of these risks and the benefits of her medications. For example, I have
attached a copy of the practice leaflet concerning benzodiazepines that was given to Miss Meredith
on 1/12/2008.

With regard to the suggestion that Miss Meredith had stockpiled her medication, I have no record
from the family or police as to the names or the quantity of this medication that was found at her

2

 flat after her death. A system of medication review would not necessarily pick up whether a patient
would be stockpiling medication. Miss Meredith would usually come to an appointment with a list of
medication  that  she  was  running  out  of.  This  would  usually  be  the  same  medication  prescribed
weekly and this would imply that she required the medicine and that she was taking it as prescribed.
The  practice  would  rely  on  the  patient  to  provide  accurate  information  about  their  use  of
medications.

I  hope  that  I  can  reassure  you  that  Miss  Meredith  had  very  careful  monitoring  of  her  medication,
including regular medication reviews, given the special weekly and monthly restrictions put in place
on  repeat  prescribing  for  her.  In  addition,  her  frequent  attendances  at  the  practice  provided
additional  opportunities  for  her  medication  to  be  reviewed  by  a  doctor.  Furthermore,  there  were
frequent and frank discussions with her about the risks of her medications and she was fully aware
of the risks and potential side effects.

2. Addition of morphine, given high dose of pain killers and alcohol dependence:

Miss Meredith had required long-term pain-relief since 2002 following her compression fracture and
fractured  ankles  when  she  jumped  from  her  first  floor  window  following  a  fire.  She  also had  long-
standing problems with abdominal pain from her appendix abscess and subsequent operations. At a
consultation on 25th February 2013, she asked for additional pain relief.

She  had  already  been  referred  to  and  seen  by  the  General  Surgeons  (9/1/2013)  regarding  her
abdominal  pain  from  her  laparotomy  operation  site.  They  had  referred  her  to  the  pain  clinic  at
Stafford DGH where she was assessed by the Consultant Anaesthetist 
(22/1/2013) who had
recommended  injections  into  her  scar.  This  was  carried  out  as  a  day  case  on  the  9/5/2013.  There
were  no  further  recommendations  made  regarding  her  analgesia  at  either  appointment.  She
attended Orthopaedic Out-patients 6 times in 2013 with the pains from her foot which was found on
MRI  to  be  a  non-healing  fracture  of  her  metatarsal.  She  was  maintained  in  a  plaster  slipper  from
15/1/2013 throughout this time to alleviate pain. Pauline had continued to complain of severe pains
from her foot, elbow and both knees. Her suffering from pain is documented in the GP notes as well
as the hospital correspondence. Other interventions apart from medications were tried to help with
her pain control. She had both knees and her elbow injected during 2013 in order to try and ease her
pain. She was also referred to community physiotherapy on 14th May 2013.

In response to her request for additional analgesia in February 2013, options were limited.  For pain
relief,  she  was  already  taking  tramadol  50mg  2  tablets  four  times  daily  (maximum  dose)  plus
paracetamol  500mg  2  tablets  four  times  daily  (maximum  dose)  and  diclofenac  50mg  three  times
daily (maximal  usual dose). I  was reluctant to prescribe  co-codamol  or codeine  or dihydrocodeine.
These had previously been prescribed with little effect on her pain. She was already on a strong anti-
inflammatory painkiller (diclofenac) and so there was little value in changing to an alternative anti-
inflammatory.  As  Miss  Meredith’s  pain  appeared  significant,  I  decided  to  prescribe  MST  (slow
release  morphine  sulphate  tablets)  1  tablet  twice  daily  at  the  lowest  dose  possible,  10mg.  The
treatment  plan  initially  was  to  prescribe  this  for  one  week  and  then  review  whilst  she  regained
control  of  her  pain.  Miss  Meredith  was  instructed  to  use  the  morphine  twice  daily  and  to  use
tramadol for any break through pain.

After  one  week  she  had  said  that  the  MST  had  helped  with  her  pain and  therefore  Miss  Meredith
asked to continue on MST 10mg twice daily. Miss Meredith continued on a weekly prescription for
MST  from  February  until  her  death  in  August  2013.She  was  asked  whether  she  found  the  MST
helpful  at  later  dates  when  her  pain-symptoms  were  discussed  and  importantly  also  after  the

3

 discussion with her mother on 15th July 2013. The continuation in prescription occurred because she
continued  to  state  that  MST  helped  her  pain.  Miss  Meredith  throughout  this  time  had  genuine
physical reasons for her pain, given her history of fractures and abdominal wall pain. I can provide
letters  from  the  orthopaedic  surgeons  that  document  the  fractured  bone  in  her  foot  and  possible
fracture in her elbow and from the pain clinic regarding her abdominal wall pains, if necessary. These
provide evidence documenting the severity of Miss Meredith’s pain.

In considering whether MST was appropriate, I took into account that her drinking had become less
frequent in the 10 months before her  death.  Rather than being dependent on alcohol, as she had
been previously, she was having frequent drink free days and drinking much less during a session.
She was well aware of my concerns about her binge drinking she had a history of excessive drinking
leading to black-outs, falls and amnesia. Her elbow injury had happened in November 2012 following
a  fall  when  drunk.  I  considered  her  alcohol  intake  when  considering  the  appropriate  analgesia  to
prescribe but was reassured by the fact that she had controlled her alcohol intake much better than
previously. In January she stated that she was still binge drinking  but had reduced the amount she
had been consuming. In a consultation with Dr Knight at the Surgery on 15th May she described her
alcohol intake as “0 units a week”.

In summary, morphine sulphate was prescribed as there were little options for her pain control and
she  was  already  on  tramadol,  paracetamol  and  diclofenac.  The  morphine  was  planned  to  work  in
combination  with  her  other  analgesic  medication.  Previously,  other  opiates  such  as  codeine  and
dihydrocodeine  had  been  ineffective.  The  MST  was  the  lowest  slow  release  formulation  and  was
issued  on  a  weekly  prescription,  therefore  regular  review  was  in  place.  The  patient  continued  to
state  that  it  did  help  with  her  pain  control.  She  had  also  curtailed  and  reduced  her  drinking
considerably and was not dependent on alcohol, and she knew about the risks of binge drinking with
her medication. It is important to also consider that, after 4-8 weeks on morphine, she would have
developed  a  tolerance  to  the  morphine  by  regular  dosing,  which  would  have  reduced  any  side-
effects and also reduced the risk of any potential toxic effects such as respiratory depression.

3. Perceived reluctance to listen to family’s concerns:
It is regretful that the family perceive that their concerns were not being listened to. I had no direct
contact with Pauline’s sisters who are not patients at the practice. At consultations over the years
when 
  had  attended  with  her  daughter,  she  had  raised  concerns  about  her
daughter’s  reliance  on  medication  which  I  had  discussed  with  Miss  Meredith  but  since  2010  Miss
Meredith had been mentally and emotionally much more stable with no overdose attempts.

, Pauline’s mother, on 15th July 2013 during a telephone consultation and
I spoke with 
took  on  board  the  comments  she  made  regarding  her  daughter’s  paranoid  thoughts  about  her
neighbours. This was the first that I knew that Pauline was arming herself at night with knives and
roping up her doors when she was in her flat at night.  
 also expressed her concern that
Pauline’s  paranoia  had  started  following  the  addition  of  MST.  For  reasons  of  confidentiality  it  was
inappropriate  to  provide  any  specific  information  about    Miss  Meredith’s  condition  or  medication
directly to her mother without Pauline’s consent but I certainly listened to these concerns.

15th JULY 2013 at 08.55

I documented the concerns:
Tel Consultation 
“Concern over daughter…. Who is anxious and agitated
Paranoid re neighbours
Putting herself and others at risk
Borderline paranoid schiphrenic
Seeing daughter later… likely to involve CMHT”

4

 I  discussed  this  with  Miss  Meredith’s  later  that  morning  in  a  consultation  that  took  22  minutes.  I
planned  to  refer  Miss  Meredith  to  the  Community  Psychiatric  Nurse  (CPN)  via  the  Mental  Health
Team based on what I had been told by her mother as well as her increasingly anxious and paranoid
thoughts.  Unfortunately  and  regretfully  this  was  not  done  that  day  and  so  was  delayed  as  I  was
working away from Stafford most of that week. In fact despite comments in the records for Pauline’s
next consultation on 22nd July, “awaiting CPNs”,  it was not until the 5th August that I realised that
the  referral  had  not  in  fact  been  made.  This  was  then  faxed  that  day  to  the  Community  Mental
Health Team.

I  wish  to  reassure  the  family  that  I  did  take  seriously  and  actively  followed-up
concern by discussing this with her daughter when I saw her later on the same day 15/7/2013 and I
continued to assess and consider these concerns during her subsequent consultations. There is no
other documented approach by any family member to the practice, expressing any other concerns.

concern about the paranoia being related to the morphine, I did not
With regard to 
consider this to be likely. Miss Meredith’s thoughts seem to be a localised paranoia as otherwise her
mental state seemed appropriate, according to the information that I had from Miss Meredith and
her family. My impression was that it would be very unusual for Morphine to trigger paranoia and
her paranoid thoughts were more likely to be a response to stressful situations.
Morphine  is  not  usually  associated  with  paranoia  or  delusions,  although  can  be  associated  with
hallucinations,  confusion  and  agitation.  I  addition,  I  considered  that  Miss  Meredith’s  paranoid
thoughts were similar to her previous episodes when she reported paranoid feelings between 2003
and 2006. At that time she had thought that she was being followed by special branch or inspectors
from  the  benefits  agency.  These  thoughts  and  feelings  persisted  for  several  years  but  were  again
well-contained and settled in due course. They did not coincide with any morphine prescribing.

Several  times  during  2013,  I  challenged  her  paranoid  way  of  thinking  and  she  did  accept  that  her
paranoid feelings could have been false thoughts rather than reality. Miss Meredith reported that
her neighbours had apparently been arrested for growing cannabis on the 14th January 2013. Miss
Meredith continued to experience stress, related to a family situation as well as to a chest infection
and then diarrhoea after visiting her brother in Cardiff. My clinical impression was that she did not
have  a  psychotic  illness  and  the  stress  was  causing  increased  paranoid  thoughts  unrelated  to
morphine prescribing but related to the many other causes of stress.

In reflecting on this point with  
 Consultant Psychiatrist and Clinical Director South
Staffordshire and Shropshire Healthcare NHS Foundation Trust, he agreed that it would be unlikely
that  the  morphine  would  cause  such  focussed  paranoid  thoughts  without  causing  a  more
generalised confusion.

I am very sorry that the family feel I had not taken their concerns on board. The family approached
the  practice  with  concerns  only  once  and  these  concerns  were  certainly  discussed  with  Miss
Meredith on the day that they had been raised by her mother. I continued to consider and assess
concerns in my subsequent interactions with Miss Meredith. Miss Meredith herself
felt  that  the  morphine  was  helpful  rather  than  causing  problems.  My  assessment  was  that  the
paranoid thoughts were not related to morphine but to Miss Meredith’s stress.

Looking  back  at  events,  it  would  have  been  useful  with  Miss  Meredith’s  consent  to  have  had  the
opportunity  to  feed  back  to  her  mother  either  directly  or  in  a  joint  consultation  with  family
members.

5

 4. The lack of team meetings to discuss challenging patients:
It  is  likely  that  I  would  have  discussed  Pauline  and  her  anxiety  and  paranoid  thinking  with  my
General Practice colleagues in an informal way, as this often occurs in the course of General Practice
when  challenging  problems  are  posed  by  patients,  but  I  cannot  recollect  when  this  may  have
occurred. Informal discussions are not recorded in the notes.

Regular  clinical  meetings  occur  at  the  practice  in  order  to  discuss  clinical  issues  and  this  often
involves patients with complex clinical and psychological problems. However, in the period prior to
her death, I did not consider there was a need to discuss Miss Meredith’s care at a meeting, as she
was  going  through  a  period  of  relative  stability.  She  was  still  receiving  a  lot  of  support  and
supervision, being seen by a doctor every week over a prolonged period of time. Her overdoses and
self-harm had curtailed significantly since 2010.

However, having considered these events as a practice, the practice will endeavour in the future to
identify  complex  patients  who  might  benefit  from  discussion  at  clinical  meetings.  These  triggers
could include concerns expressed by doctors, relatives, neighbours and other organisations such as
police and housing.

5. Approach to involving community mental health services:
The  report  raises  a  concern  that  there  could  have  been  a  more  timely  approach  to  involving
community health services.

Browning  Street  Surgery  has  established  a  reputation  locally  for  supporting  patients  who  are
vulnerable  and  with  complex  mental  health  needs.  Over  the  last  18  years  as  a  GP  partner  and
especially  in  my  role  as  Clinical  Champion  for  Mental  Health  I  have  been  an  advocate  for  patients
with mental illness and have been constructively critical of failings in mental health services. I have
also  been  involved  in  introducing  the  current  primary  care  mental  health  service  into  South
Staffordshire. I have lectured and given presentations on mental health services and treatments at
GP and Commissioners at conferences in Staffordshire and the West Midlands.

The  partners  in  the  practice  have  discussed  the  circumstances  around  Miss  Meredith’s  death  and
have  considered  whether  involvement  of  mental  health  services  any  sooner  would  actually  have
made any difference to the eventual outcome.

Miss Meredith was referred to specialist mental health services on 5th  August,  3  weeks  before  she
inadvertently took an overdose. A letter from the Community Mental Health Team was sent to the
patient (and copied to the practice) dated 6th August 2013, inviting the patient to  contact them  to
arrange an appointment. This was received at the practice on 13th August.

Miss Meredith was last seen by any form of mental health service following an impulsive overdose in
November  2010.  She  was  reviewed  by  liaison  psychiatry  whilst  in  Stafford  DGH  following  her
overdose. There is a letter from psychiatry from earlier that year, dated 26th March 2010 stating that
Miss  Meredith    had  not  attended  2  appointments  with 
  Consultant  Psychiatrist,  which
resulted in her being discharged.

Other mental health contacts are documented below:
She  had  been  referred  in  2003  to 
  Consultant  Psychiatrist  and  also  to  the  Community
Psychiatric  Nurse  with  paranoid  ideas.  At  this  time  her  levels  of  stress  had  provoked  paranoid
thoughts  that  she  was  being  followed.  These  thoughts  were  well  contained  and  did  not  interfere
with  her  normal  functioning.  They  continued  for  several  years  last  being  mentioned  in  2006.  She
initially thought this was special branch and related to her Northern Irish connections but later was

6

 concerned that it was inspectors from the Benefits Agency checking up on her. Her paranoid thinking
diminished in due course.
She was referred again in 2005 to the Community Mental Health team and again she did not attend
any appointments.

Since then she had contact with mental health services on the following dates:
20.11.2009;  Liaison  Psychiatry  at  Stafford  DGH  following  overdose,  referred  to  Community  Mental
Health Team (CMHT) and also to Crisis Service. Miss Meredith failed to engage with either service.
22.12.2009;  Liaison  Psychiatry  at  Stafford  DGH  following  overdose.  She  was  referred  to 
Consultant  Psychiatrist.  She  was  offered  two  appointments  but  failed  to  keep  either  and  so  was
discharged from mental health services.
5.5.2010; She was referred to ADSiS (Stafford based alcohol support service) where Miss Meredith
attended several appointments with the support worker at the surgery.
12.5.2010;  She  attended  Stafford  Accident  and  Emergency  following  an  overdose  and  with
superficial lacerations to wrist.  The following day, she re-attended Stafford Accident and Emergency
with further lacerations. She assessed by the Liaison Psychiatry Team and was referred to the Crisis
Team but failed to engage.
25.7.2010; Miss Meredith cut her wrists and was admitted via at Stafford Accident and Emergency
with  a  significant  laceration  to  her  wrist  requiring  reconstructive  tendon  surgery  under  the
Orthopaedic Surgeons. No mental health input was documented.
5.11.2010; Miss Meredith took an overdose of paracetamol requiring admission and treatment. She
was  assessed  by  the  Liaison  Psychiatry  Team  but  no  further  follow  up  was  arranged  with  Mental
Health Services.

Paranoid Thoughts:
I  have  studied  the  medical  notes  regarding  Miss  Meredith’s  thoughts  and  concerns  about  her
neighbours and this is shown below:
12th  November  2012, Miss  Meredith  had  stated  that  she  had  been  up  all  night  as  her  neighbours
were making too much noise all night.
On 14th January 2013, she stated that her neighbour had been arrested for growing cannabis. There
are then no further documented concerns about her neighbours until a consultation on 25th March.
Her  consultations  were  preoccupied  with  other  stresses  and  also  a  severe  bout  of  infective
diarrhoea.
On 22nd April and 4th May, Miss Meredith expressed further stress with her neighbours and on the
later date I suggested a referral to the Community Mental Health Team. This she declined.
The next recorded comment about her neighbours is the 3rd June. This was the night she claimed to
have been beaten up by “druggies” and then arrested by the police. She attended Stafford Accident
and Emergency on the 6th June with injuries that she  claimed had arisen from these events 3 days
earlier.
The following week on the 10th June, Miss Meredith said that she felt threatened by her neighbour.
It  was  not  until  1st  July  that  Miss  Meredith  expressed  more  extreme  thoughts  to  me  that  she  was
being  “bugged  or  followed”.  Her  thoughts  seemed  contained  to  her  flat  and  neighbours  with  no
other disturbed thinking. The consultation was described in the medical notes as a “frank discussion
about concerns if paranoia started being overwhelming. Still claims that she feels relaxed at home”. I
rang her the following day and she had slept well and said that she was more settled.
The following week on 8th July, Miss Meredith was agitated and stressed after rows with her mother.
Again I  suggested  a  referral  to  mental  health  services  either  the  Community  Mental  Health  Team
(specialist  mental  health  service)  or  Emotional  Wellbeing  in  Stafford  and  Surrounds  (primary  care
mental health service).

7

 Miss Meredith was reluctant to be referred to the Community Mental Health Team and the subject
of  referral  was  broached  with  her  on  several  occasions  7/5/2013,  1/7/2013,  8/7/2013  and
15/7/2013. She finally consented to a referral on 15th July. I was sceptical as to whether she would
engage or also how useful that additional support would be.
Inadvertently although I thought this referral had been made on 15th July, it was in fact overlooked
that week as I was working elsewhere. I referred Miss Meredith to the Community Mental Health
Team on 5/8/2013 causing a delay of 2 weeks. I have copies of two letters sent by the CMHT to her
asking her to make contact by ringing the Team in order to make an appointment. These are dated
6th August and 23rd August.

I  saw  Pauline  on  5th  August  and  then  16th  August  before  I  was  due  on  leave  for  two  weeks.  Her
mental state appeared anxious but not psychotic. She was agitated and continued to have paranoid
thoughts  focussed  on  her  neighbours.  She  appeared  to  be  functioning  and  was  still  seeing  her
mother regularly. Even at the inquest the family said she had been in good spirits and “upbeat” the
evening before her death.

During my absence, Pauline was also seen by North Staffs A/E and admitted overnight with melaena
to University Hospital North Staffordshire (20th -21st August 2013). She also attended Stafford A/E on
27th  August  with  her  foot  pain.  She  had  already  had  a  review  by  orthopaedic  consultant  on  2nd
August. There is no comment about the deceased’s mental state in any correspondence.
I was not aware of the number of frequent police contacts until after her death, when a letter dated
27th August 2013 arrived from the Neighbourhood Police Team.

Summary:  Miss  Meredith  had  been  much  more  stable  since  a  difficult  period  in  2009-2010  which
was  associated  with  overdoses  and  self-harm  during  which  she  had  never  engaged  with  mental
health support. In 2013, she was dealing with significant levels of family stress and had developed
paranoid ideas about her neighbours. Otherwise her mental state although anxious was certainly not
psychotic  and  she  continued  to  function  relatively  normally.  Miss  Meredith  refused  to  accept  a
referral to mental health services on at least 3 times between May and July 2013 when I suggested
it.  There  was  no  time  when  she  was  so  disturbed  that  she  could  have  been  sectioned  under  the
Mental Health Act. She maintained capacity and so had to consent to any referral being made. It was
not  until  15th  July  2013,  using  the  information  obtained  from  the  telephone  consultation  with  her
mother,  that  I  was  able  to  persuade  Pauline  to  accept  additional  mental  health  support.
Unfortunately, the referral was inadvertently delayed, eventually being faxed on 5th August and the
Community Mental Health Team sent her an initial contact letter dated 6th August 2013 followed by
a second letter on 23rd August.

Actions to be taken
As a practice, we have carefully discussed these events to determine personal learning or any need
for  changes  to  practice  processes.    The  practice  has  considered    three  strategies  following  the
Coroner’s Inquest;

1)  We  have  formally  instigated  a  programme  of  regular  practice  meetings  which  will  look  at  all
deaths in the under 50’s. In the past this has been adhoc but now the process will be more formal.
Deaths  in  young  people  are  infrequent  but  also  extremely  significant  and  the  practice  wishes  to
ensure all that can be done is done to prevent these. A protocol for this will be written and agreed
within  the  next  month.  The  first  meeting  will  take  place  in  the  next  2  months  and  will  continue
thereafter.

2)  The  practice  will  endeavour  in  the  future  to  identify  complex  patients  who  might  benefit  from
discussion at clinical meetings. The practice is currently considering how to select patients for these

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 meetings  in  a  more  structured  way.  These  triggers  could  include  concerns  expressed  by  doctors,
relatives, neighbours and other organisations such as police and housing.  The practice would hope
to define the criteria for identifying these patients, draw up a protocol for these meetings and hold
its first meeting within the next 2 months.

3) Miss Meredith had seen 3 other doctors and the nurse practitioner in previous 8 months before
her  death.  Having  reflected  on  this  case,  I  recognise  that  it  can  often  be  useful  to  have  another
clinician  with  a  fresh  pair  of  eyes  looking  at  patients  with  chronic  problems.  The  practice  will
consider  whether  there  are  circumstances  where  the  medication  reviews  are  best  carried  out  by
another doctor who is not so involved with the case. This would be actioned by the regular doctor
asking for a medication review by a colleague who was not involved in management of the case. This
is to be initiated from now.

Personally,  I  will  continue  to  strive  to  complete  all  referrals  at  the  time  of  the  consultation  rather
than risk delay in a referral being made.

Additional Comments and Summary
You have raised 5 concerns which have been addressed in this response:

1)  The  amount  of  medication  prescribed  as  related  to  multiple  physical  and  mental  health
problems.
Medication  was  prescribed  in  a  controlled  way  with  weekly  prescriptions  following  weekly
consultations.  Routine  formal  medication  reviews  of  her  medication  did  take  place  and  the  final
formal  review  before  the  date  of  her  death  was  carried  out  on  24/6/2013.  In  addition,  Miss
Meredith  had  frequent  consultations  and  each  consultation  afforded  the  opportunity  to  review
medication.  The  patient  was  aware  of  the  risks  if  her  medication  was  misused  and  there  is
documented evidence of this. The practice will consider whether complex medication reviews would
be better carried out by a doctor who is not directly involved with the patient.

2) The addition of morphine given existing pain relief medications and history of alcohol
Morphine  was  instigated  following  a  lack  of  response  to  a  combination  of  strong  pain-killers
(tramadol/paracetamol)  and  anti-inflammatory  tablets  (diclofenac),  to  treat  conditions  that  were
causing  significant  pain.  The  morphine  was  intended  to  work  in  combination  with  her  other
medications. Miss Meredith had improved her alcohol intake considerably.
Although initially started as short term, Miss Meredith claimed to find benefit from morphine and so
it  was  continued.  It  was  the  lowest  dose  of  slow-release  morphine  and  was  prescribed  in  weekly
prescriptions with usually a weekly consultation to monitor progress.

3) The family perceived a reluctance to listen to their concerns

was able to discuss her concerns with me. She discussed her concerns about morphine
and paranoid thoughts during a telephone consultation on 15th July. The information she passed on
about  her  daughter  was  important  to  me  and  I  very  much  considered  this  valuable  and  helped  to
inform me as to the circumstances at home. Her concerns were in fact discussed with Miss Meredith
on  the  same  day  that  her  mother  had  expressed  them.  The information  she  passed  on  about  her
daughter was important and helped me persuade Pauline that she needed help and to finally agree
to a referral to the Community Mental Health Team.

4) Team meetings to discuss challenging patients
There are regular team meetings held at the practice. These discuss many issues including significant
events and care planning of frequent attenders at A/E. In the future, the practice will endeavour to
identify patients with additional complex needs for specific discussion at practice meetings.

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 5) The lack of timely proactive approach to mental health services
Miss Meredith had paranoid thoughts in the past but these had settled. She had been reluctant to
engage  with  mental  health  services  previously  and  refused  to  consent  to  a  referral  until  15th  July
2013.  She  was  assessed  as  having  capacity  to  make  this  decision  and  admission  under  the  Mental
Health  Act  was  not  appropriate.  When  a  referral  was  made  for  additional  support  on  5th  August,
Pauline  should  have  received  a  letter  from  the  Community  Mental  Health  Team  dated  6th  August
within a few days. She should have then received a second invitation letter dated 23rd August. Both
letters asked her to contact the mental health team’s telephone number to arrange an appointment.
This  is  the  appropriate  referral  process  for  the  Community  Mental  Health  Team  within  the  South
Staffordshire and Shropshire Healthcare NHS Foundation Trust.

The practice aims to  maximise the health and wellbeing of our patients. We endeavour to provide
excellent care for our many vulnerable patients with complex mental health needs. Miss Meredith
died  after  inadvertently  overdosing  herself  with  prescribed  medication.  It  must  be  acknowledged
that  she  had  very  complex  medical  and  psychological  complaints  and  made  informed  decisions
about  the  risks  of  her  medications  and  about  recommendations  made  to  her  to  accept  a  mental
health referral. However, the practice is keen to implement change in order to improve our service
to patients and will introduce the steps laid out in this response.

I hope this response addresses and reassures your concerns about my support for Miss Meredith as
well as the service provision at Browning Street Surgery.

Yours sincerely,

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