Judith Saville

AXMINSTER MEDICAL PRACTICE

St Thomas Court, Church Street, Axminster, Devon, EX13 5AG
Telephone 01297 32126 * Fax 01297 35759 * Secretaries Fax: 01297 32300

Andrew J Cox

HM Assistant Coroner

Exeter & Greater Devon Coroner’s Officer

Room 226 Devon County Hall

Topsham Road

Exeter

Devon RECEIVED 1 6 FEB 28%
EX2 4QD

'

Dear Mr Cox,

Mrs Judith Anne Saville d.o.b. 18.09.1943; d.o.d 28.01.2014:

Further to my previous reply to you, we have now discussed Mrs Saville’s sad death and the
issues that you raised.

I shall address the two points you raised with me individually.

Firstly, although in an ideal world Zopiclone would only be used in short courses, it is
common for this to be disregarded by patients, and where it seems the only way of relieving
their distress at being unable to sleep we do sometimes have to use it on a regular basis.
Unfortunately, it is not unusual for people to take 15mgs daily even though we normally try
to persuade them to reduce or stop this medication where possible. However, sometimes
continuing the medication regularly is the lesser of two evils.

In the situation in which normally we prescribe Zopiclone, short courses of limited numbers
of pills are advisable and our computer system automatically offers us this choice with a label
which advises against repeat or regular use. There will inevitably be some patients for whom
it has been decided that a regular prescription of one months supply is appropriate. In Mrs
Saville’s particular circumstance we would not necessarily agree a prescribed too
many zopiclone pills, although we sympathise with his comments. Viewing her prescribing
records it appears that she was not prescribed on any single occasion more than a months
supply at the dose had decided on. We would certainly all agree that in cases where
there is a heightened risk of suicide we would endeavour to restrict supplies of potentially
toxic medication of any type. Our local pharmacists and dispensers do also flag to us when
patients appear to be requesting medications earlier than would be expected. As you will
understand however, restricting prescribed medications would not prevent patients who have
chosen to “stockpile” regular medications from holding large numbers of any pill which we
prescribe regularly. There are many medications which are much more toxic than zopiclone
and of course many over the counter medications which would also be toxic in overdose.

Dr P.J.R Taylor « Dr J.G Halford ¢ Dr J.M Allen
Dr S.A Ellis » Dr BN McKenna « Dr S.J Mount « Dr E.P Guinness ° Dr L.C Crosby « Dr J Ashby
GP Assistants: Dr Y.M.B Hodges * Dr C.E Bates « Dr A Beazley

Axminster Medical Practice 06 February 2015

Your recommendations have lead us to consider the methods available to GPs in assessing
whether a patient might have an increased risk of suicide. Mrs Saville’s medical records
record clearly in the summary that she had taken two overdoses, one in 1994 after what is
described as a marriage break-up and another in 2010. All the GP’s agreed that it would be a
normal part of assessing a patient to look at the summary page which is clear and easily
accessible. All the information contained therein would normally be taken into account
especially if it is relevant to the reason a patient is consulting. To have a special flag which
highlights that a patient has taken overdoses in the past would be problematic because this is
not relevant information for many such people and significant numbers of patient have taken
overdoses in the past but are not at increased risk of repeating any form of self-harm. Patients
rightly expect that their medical records are both accurate and do not stress information
which might in some way be viewed as judgemental and a special flag or message which is
given more weight than any other part of their medical history might well be offensive to
some.

In Mrs Saville’s case it is important to consider what action might have resulted if there had
been a flag which suggested an increased risk of suicide. All the GP’s present agreed that this
might have prompted urgent referral to the Crisis Response Team for an assessment including
the current suicide risk. The Crisis Team always guide us if they believe that a heightened
risk should temporarily (or permanently) change our patterns of prescribing. I understand that
this referral was made and Mrs Saville was seen.

I believe that the wider GP community as a whole is likely to hold similar views and if you
wish this could be raised with the Local Medical Committee who could advise us
accordingly.

I hope that you will find this reply satisfactory and shows that we have given your
recommendations very careful consideration. The very fact of doing this will mean that the
tisk of a suicide remains an important factor in assessing anyone with psychological
problems. If raising this with us makes a difference to just one patient in the future then it
will have been worthwhile.

Devon Partnership NHS

NHS Trust

Trust Headquarters
Wonford House Hospital

, Dryden Road
RECEIVED 1 7 MAR 2015 Exeter
EX2 5AF
Mr A Cox Telephone: 01392 208866
HM Assistant Coroner Web: www.devonpartnership.nhs.uk
Exeter and Greater Devon Coroner's Office
Room 226 Your Ref: Po
Devon County Hall
Exeter 41 March 2015
EX2 4QD
Dear Mr Cox

Re: Judith Anne Saville - Regulation 28 Report to Prevent Future Deaths

Thank you for your letter of the 15"" January 2015 which we received on the 20" January 2015
following the inquest into the death of Judith Anne Saville. As an organisation we are committed to
learning from these tragic events and have since receiving your report and recommendations taken
the opportunity to share your findings with the service involved as well as across the wider trust.

As you noted at inquest the Trust undertook a Root Cause Analysis Investigation following the death,
the Root Cause Analysis report contained a number of recommendations; all of which were accepted
and the actions have now been completed.

| have attached a summary which details the actions identified in the original RCA and the progress
made against each of these actions. Whilst we have been able to complete the actions that were
identified in the original Root Cause Analysis, the assurance that changes have been fully embedded
into clinical practice is monitored through routine audit and this represents part of our continuing
programme of quality improvement. As such we would expect to see on-going improvement over the
coming months. Additionally every RCA action and evidence to support their closure is reviewed by
our commissioner before the action plan can be formally closed.

| hope that the actions described demonstrate our commitment to the learning we have undertaken. If
you require any further information please do not hesitate to contact me.

Yours sincerely

Melanie Walker
Chief Executive

Chair: JulieDent CBE - Chief Executive: Melanie Walker

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