Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0179, written 6 Jun 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jun 2017 |
|---|---|
| Reference | 2017-0179 |
| Deceased | George Cheese |
| Coroner | Peter Bedford |
| Coroner area | Berkshire |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Classification: OFFICIAL-SENSITIVE REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Director of Primary Care: Woodley Centre Surgery, 1st Floor, 6 Headley Road, Woodley, Reading, RG5 4JA. 1. CORONER I am Peter James Bedford, Senior Coroner, for the coroner area of Berkshire. 2. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3. INVESTIGATION and INQUEST I conducted an Inquest into the death of Mr George Arthur Cheese that was heard at Reading Town Hall between the 23rd and 25th May 2017 inclusive. The conclusion of the Inquest was that Mr Cheese took his own life whilst suffering from a depressive disorder brought on by a series of life events. A full copy of the Narrative Conclusion is attached. 4. CIRCUMSTANCES OF THE DEATH Mr Cheese was an 18 year old young man who was found hanging in Woodland near his home address on 9th April 2015. He had a number of ongoing issues in his life including the potential loss of a career in the army; a fluctuating relationship with his girlfriend; an unsubstantiated concern that he might have a serious illness and he had been subject to upsetting treatment by his colleagues at work. He was under the care of his GP surgery and the local Mental Health Team who were treating him for anxiety and depression including prescribing anti- depressant medication. Classification: OFFICIAL-SENSITIVE -1- Classification: OFFICIAL-SENSITIVE REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 5. CORONER’S CONCERNS During the course of the Inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless this action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) While the evidence at the Inquest dealt with the various matters ongoing in Mr Cheese’s life, I also heard evidence of the care and treatment that he received from his GP surgery. One of the doctors at the surgery, gave live evidence at the Inquest. (2) Mr Cheese was prescribed Fluoxetine anti-depressant medication on the 3rd November 2014 by a treating GP, following admitting to fleeting on 14th January 2015 suicidal thoughts. He was reviewed by when Mr Cheese described daily episodes of intense low mood with suicidal thoughts which included taking an overdose. This led to a reference to the Mental Health Team. At an appointment with the Practice’s Nurse Practitioner on 3rd February, Mr Cheese was prescribed 112 tablets of Fluoxetine. In the course of her evidence, stated that the Nurse Practitioner was probably just repeating the same prescription that the previous Doctor had issued to Mr Cheese but that she, , would not have done that. (3) also acknowledged, in the course of her evidence, that there was no “flag” on Mr Cheese’s notes to alert treating Clinicians within the GP Practise to limit the amount of medication provided to Mr Cheese in view of his history. She acknowledged that a flag, in such circumstances, was good practise. (4) The concerns arising from the evidence are therefore the amount of medication prescribed to a patient who was known to be suffering from mental health issues and describing suicidal thoughts and a potential overdose and the fact that this was not being flagged to prevent large amounts of medication being provided to him as a matter of repeat prescription. 6. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths in such circumstances and I believe your Surgery has the power to take such action. Classification: OFFICIAL-SENSITIVE -2- Classification: OFFICIAL-SENSITIVE REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd August 2017. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the family of Mr Cheese. You are also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9. 6th June 2017 Peter J. Bedford Senior Coroner for Berkshire Classification: OFFICIAL-SENSITIVE -3-
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
3 Westfield Road, Winnersh Wokingham, Berkshire RG41 SES Tei 0118 969 7307 » Fax 0118 9770731 ist Floor, 6 Headley Road Woodley, Reading, Berkshire ROS 44 Tei 0118 9697307 © Fax 0118 9272632 Please reply to: Woodley 27 July 2017 Mr Peter | Bedford Senior Coroner for Berkshire Reading Town Hall Blagrave Street Reading RGi 10H Reference: PIB Cheese Dear Mr Bedford, Thank you for your letter and report dated 6" June requesting the surgery’s response to your concerns raised at the inquest of George Cheese about the large number of antidepressant tablets prescribed to him without adequate review. | enclose a copy of our antidepressant prescribing policy; the result of discussions with my partners which | hope will answer those concerns. Shortly after George died the partners introduced the requirement for the issue of repeat prescriptions and depression reviews to be conducted by GPs only; receptionists are aware that patients with anxiety and depression cannot be seen by nurse practitioners. This policy has been circulated to all our GPs and nurses/nurse practitioners, The addition of a flag - or ‘major alert’ - on the front screen of the patient’s record is the responsibility of the GP who initially assesses or reviews the patient should they have concerns at any time. This could include receiving a letter from Talking Therapies expressing concern about a patient's suicidal thoughts. | have written up the role of the clinicians including the issue of 112 capsules of fluoxetine to George on 2 occasions as a ‘significant event’ and will be discussing this at our next clinical meeting on Thursday 27" July. Anaiysis of significant events is a requirement of the CQC (Care Quality Commission) inspection to demonstrate that events that have been detrimental to patient care have been identified, discussed and lessons have been learnt with the aim of improving the quality of care. We have also arranged for a consultant psychiatrist from the local mental health team to talk about management of mental heaith disorders at our clinical meeting scheduled for Wednesday 23 August. | hope that these policy changes together with discussion and education will reduce the risk of overdose to any patient in future. Yours sincerely Jo ; if www.woodleycentresurgery.co.uk Woodley Centre Surgery Safe antidepressant prescribing policy A feature of patients suffering from depression is an increased tendency to have suicidal thoughts and subsequently atternpt suicide. Such patients are often prescribed antidepressant medication; regrettably this may lead to the patient taking an overdose, sometimes with a fatal result. To reduce this risk doctors must review the patient regularly and prescribe the minimum number of tablets, paying particular attention at initiation of medication and dosage increases, in view of the increased tendency to overdose at these vulnerable times. See NICE guidance: Depression in adults: recognition and management 2016 and Depression in children and young people 2015. * Consider prescribing only 7-14 days antidepressant treatment at initiation particularly in people under the age of 30 ® The norm for continued prescribing is 28 days treatment; the maximum is 56 days for all antidepressants. ® Hf the patient is stable and 56 Gays is considered appropriate please write the justification for this in the patient’s notes. ® Ifa patient attends for another problem and is taking antidepressants please review the depressive illness and record this discussion in the notes. e Please use the depression template to record the discussion and medication review. * Nurse practitioners must refer Patients with depression to a GP and should not initiate antidepressants themselves, issue prescriptions previously prescribed by a GP or sign repeat prescriptions for antidepressants. * A flag (‘major alert’) shall be added by the responsible GP to the front screen of any patient under the care of the Mental Health Team or Taiking Therapies for a history of suicidal thoughts stating that medication can only be prescribed in smali amounts and oniy after the patient has been reviewed. A GP can add this flag for any other patient they consider at risk of suicide. WES. Antidepressant prescription policy. June 2017
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