Carly Gordon

evon

Mr John Tomalin

H.M Deputy Coroner for Exeter and Greater Devon
Exeter and Greater Devon Coroner’s Office

Room 226

Devon County Hall

Topsham Road

Exeter

EX2 4DQ

Dear Mr Tomalin

Re: Regulation 28 Report
Reference: JGT / SJ File No: 1307-2016

Deer Park Business Centre
Haldon Hill

Kennford

Exeter, EX6 7XX

Tel: 01392 834020 Fax: 01392 833339
admin@devonimc.org www.devonimc.org

7" November 2017

Thank you for your letter dated 10" August 2017, | apologise for the delay in responding.

Devon LMC is dedicated to maintaining high standards of care and professionalism and is very happy to help
disseminate important information in an appropriate manner to our members and constituent practices. | can
confirm the LMC, via our regular electronic newsletter, will remind practices regarding review of patients

receiving short acting Benzodiazepines.

In addition, we will ensure the information is made available on our website. Please could | ask you to provide a

link to the relevant documentation?

Once again, | apologise for the delay and | look forward to your reply.

Kind Regards

Chair of Devon LMC

lead, Represe nt, Inform and Support Gene al Practice

RECEIVED 2 6 SEP 2017

Fremington Medical Centre

11/13 Beards Road
Fremington
Barnstaple

EX31 2PG

Tel: 01271 376655
Fax: 01271 321006
www.fremington.org

19" September 2017

Strictly Private and Confidential
H.M Coroner

County Hall

Topsham Road

EXETER

Devon

EX2 4QD

Dear Sir/Madam

Re: Carly Marie Gordon D.O.B. 11/04/1980

Deceased D.O.D. 27/05/2016

Thank you for your regulation 28 report on Carly Gordon.

| note your concerns during the course of the inquest were twofold for our practice.

1) The long term use of shorter acting Benzodiazepine instead of longer acting Benzodiazepine in
accordance with the British Association of Psychopharmacology (BAP) Guidelines should be
followed when patients are prescribed this drug to avoid dependence.

| have read thoroughly both:

a) BAP updated guidelines: Evidence-based guidelines for the pharmacological management of
substance abuse, harmful use, addiction and comorbidity (May 2012)

b) Benzodiazepines: Risks and benefits. A reconsideration (Nov 2013)

The key points for Benzodiazepine dependence from Guideline (May 2012) are:

© “Where dependence is established, gradual dose reduction of prescribes Benzodiazepine is
recommended”.

During my regular reviews of Carly this was discussed and carried out. It was made clear at
the start of prescribing this should not be for long term use, however as | will discuss later,
clinical indications meant the use of Lorazepam continued longer than either myself or the
patient would have wanted at initiation.

Fremington Medical Centre

11/13 Beards Road
Fremington
Barnstaple

EX31 2PG

Tel: 01271 376655
Fax: 01271 321006
www.fremington.org

e “Switching from a short half-life Benzodiazepine to a long half-life Benzodiazepine before
gradual taper should be reserved for patients having problematic withdrawal symptoms”.

In this case at the time | felt the clinical indication for Lorazepam outweighed the risks. | did
not swap for a long active Benzodiazepine. | have reflected on this decision and ! will
change any future prescribing practice.

e “Additional psychological therapies increase the effectiveness of gradua! dose reduction
particularly in individuals with insomnia and panic disorder”.

| asked Carly to call (which she did) the Depression and Anxiety Service twice and referred
her to our local Psychiatric team.

The Key points | have taken and reflected upon from the BAP paper in 2013:

“Whenever Benzodiazepines are prescribed, the potential for dependence or other harmful effects must be
considered. The balance of risks and benefits with Benzodiazepines or alternative interventions in an
individual patient can be hard to assess, and is ultimately a matter of clinical judgment”.

e | felt and recall in numerous review consultations that the benefits of prescribing in the first
6-12 months for Carly outweighed the risks. In point 7 of the BAP commentary on page 971
it makes the point:

‘Many health professionals have been dissatisfied with the previous guidance that
Benzodiazepines should be used for short-term treatment only and no longer than four
weeks in regular dosage. All patients should be made aware of the risks of dependence if
they continue Benzodiazepines in regular dosage over a longer period. (I recall discussing
this with Carly). A clinical judgment has to be made as to whether alterations may be more
suitable for each patient, and for proposed medication’.

When it became obvious little progress was being made | sought specialist consultant
psychiatric advice. Carly was told at that appointment to stop the Lorazepam. We then
embarked on a gradual reduction (although her perception at the consultant appointment
was to stop it immediately) however she did not use the alternative antidepressant as
suggested.

Fremington Medical Centre

11/13 Beards Road
Fremington
Barnstaple

EX31 2PG

Tel: 01271 376655
Fax: 01271 321006
www.fremington.org

“Benzodiazepines anxiolytics should be prescribed primarily either for the short-term relief of severe anxiety
symptoms, or where anxiety disorders are disabling and severe and causing both significant personal
distress and substantial impairment of daily activities”.

“Dependence is more likely with higher dosages but can also occur with lower doses and formulations of
compounds at lower strengths and with longer half-lives may be useful in helping patients reduce from
higher doses. Even after short-term use, a tapering off regime, i.e., at least two weeks at reduced dosage,
should be considered to minimize the risk of rebound phenomena, that is the reappearance of symptoms
present prior to treatment”.

In regard to my own personal prescribing | have audited every patient | have prescribed Lorazepam to
between 27/05/2016 and 13/09/2017.

There have been thirteen patients in total. | have looked at all the notes. Of those thirteen, ten patients are
not currently being prescribed Lorazepam. Those ten were either given one off scripts or very limited
amounts (all less than two months).

The remaining three have Lorazepam on repeat prescription.

| have thus also audited every patient in the practice who has Lorazepam on repeat prescription; there are
eighteen (including the three | have prescribed for in the above time period). Of those eighteen, five
patients live in long-term residential care for learning disabled and their medication is managed by a
consultant psychiatrist.

The practice currently has twenty patients whom have either 2mg or 5mg of a long-acting Benzodiazepine,
Diazepam, on repeat: two of which live in the aforementioned residential home.

Fremington Medical Centre

11/13 Beards Road
Fremington
Barnstaple

EX31 2PG

Tel: 01271 376655
Fax: 01271 321006
www. fremington.org

2) All patients who receive this drug for an extended period of time should be reviewed by their
medical advisors to reassess their suitability for the long term use of this particular
medication.

Reviewing medication is regular practice at our surgery. However we have now considered a structured
systemic approach for patients on Benzodiazepines to those reviews following our own significant event
discussion of this case and the regulation 28 report.

For those patients who have a Benzodiazepine on repeat prescription, each have received a personal letter
from their own General Practitioner asking them to contact us for a targeted medication review of their
Benzodiazepine.

We have made a commitment not to add (or continue repeat prescriptions from patients registering from
other practices) Benzodiazepines to a repeat prescription if not already on repeat.

For those thought requiring acute prescriptions we have reminded prescribing staff of the requirement to
discuss with patients about the short term use of Benzodiazepines and regular reviews of both symptoms
and prescriptions; also, not to add these medications to repeat prescriptions. | hope my own personal audit
evidences that.

Further action taken:
e { have referred myself voluntarily to the Deputy Medical Director/RO Appraisal,
idation, Performance Lead NHS England Devon, Cornwall, Isles of Scilly Area Team, i
This is in order for her to review my performance in the management of
Carly Gordon.
e {have significantly reflected on this case and will discuss this with my appraiser.
1 would like to say on a personal note how sorry | am that | could not help Carly more. She and | had an
excellent rapport and for a long period of time she was really improving from her lifelong anxiety; she found

a job and was becoming more confident. | was and still am deeply shocked by her death and my thoughts
go out to her family.

Yours sincerely

vec.

RECEIVED - 6 aah NHS |

England

Professor Sir Bruce Keogh
National Medical Director

John G Tomalin Skipton House
Deputy Coroner 80 London Road
Exeter and Greater Devon Coroner's SE1 6LH
Office ;

Room 226

Devon County Hall

Topsham Road

Exeter : .

EX2 4QD ZG september 2017

Dear Mr Tomalin
Re: Regulation 28 Report — Carly Marie Gordon (died 25.05.2016)

Thank you for your letter and Regulation 28 report dated 17th August 2017.

| am very sorry to hear of the tragic death of Ms Gordon and please extend my
sympathy to her family.

You raise two concerns:

1) The long term use of shortér acting benzodiazepine instead of longer
acting benzodiazepine in accordance with the British Association of
Psychopharmacology guidelines should be followed when patients are
prescribed this drug to avoid dependence;.and

2) All patients who receive this drug for an extended period of time should be
reviewed by their medical advisors to assess their suitability for the long
term use of this particular medication.

In November 2013 the Psychopharmacology Special Interest Group of the Royal
College of Psychiatrists and the British Association for Psychopharmacology
(BAP) published a joint statement, with recommendations on the use of
benzodiazepines in a paper entitled Benzodiazepines: Risks and benefits
(Journal of Psychopharmacology 27(11) 967-971).

In their paper the authors recognised the existence of widespread concerns
about the use of benzodiazepines and related drugs. They also stated that
whenever benzodiazepines are prescribed, the potential for dependence or other
harmful effects must be considered. They also recognised that, when prescribing
these medicines, the risks of dependence associated with their long-term use
should be balanced against the benefits of using short or intermittent courses of

High quality care for all, now and for future generations

these. agents, as well as the risks of the underlying conditions for which treatment
is being provided.

Whilst recognising the difficulties facing clinicians, the BAP guidance entitled
Benzodiazepines: Risks and benefits supports an individualised approach to
prescribing, based on clinical judgement, with the involvement of patients and
carers (where appropriate) in the prescribing decision.

Overall, the BAP guidance supports best practice as the short term or intermittent
use of benzodiazepines, but also accepts that for a minority of patients longer
term treatment may be appropriate; but in all cases vigilance of potential hazards
is required throughout treatment.

“The balance of risks and benefits with benzodiazepines or alternative
interventions in an individual patient can be hard to assess, and is ultimately a
matter of clinical judgment.”

Advice on best practice in the management of benzodiazepine withdrawal is

available through the National Institute of Health and Care Excellence (NICE)

series of clinical knowledge summaries (CKS) available at
-withdrawal#!scenario.

This topic covers the management of people who are prescribed long term
benzodiazepine treatment and offers advice on the management of withdrawal of
treatment.

It is important that prescribers and pharmacists are aware of the risks associated

with the use of benzodiazepines when prescribing or dispensing these

medicines. In response to the specific concerns raised in your letter, | will ask
our National Clinical Director for mental health, and |

Mou Head of Mental Health and LD Medicines Strategy to write to all medical

directors and chief pharmacists in mental health trusts in England to;

1) Ask them to take a lead on raising prescribers’ and pharmacists’
awareness of the risks associated with benzodiazepine prescribing and
withdrawal across their local health community;

2) Stress the importance of regular and close monitoring of patients who are
withdrawing from benzodiazepines; /

3) Highlight the risks associated with short acting benzodiazepines in
particular;

4) Remind them of the statements and guidance published by the BAP and
NICE clinical knowledge summaries; and ,

5) Raise the issues within their local area prescribing committees to ensure
dissemination across both primary and secondary care prescribers.

High quality care for all, now and for future generations

| hope this provides you with the reassurance that NHS England is responding to
your concerns and taking action to raise awareness of best practice guidance on

benzodiazepine prescribing.

Yours sincerely,

Professor Sir Bruce Keogh KBE, MD, DSc, FRCS, FRCP

National Medical Director
NHS England

High quality care for all, now and for future generations

RC Royal College of
G P General Practitioners

Dr Jonathan Leach MB ChB MSc(Med) FRCGP DRCOG DIMC RCS(Ed)
Joint Honorary Secretary (elect)

FAO Mr John G Tomalin

Exeter and Greater Devon Coroner’s Office :

Room 226 .

Devon County Hall RECEIVED 2 8 SEP 2017
Topsham Road
Exeter

EX2 4QD

27 September 2017
Dear Mr Tomalin,

Inquest into the death of Carly Marie Gordon - RCGP response

Thank you for your letter seeking comments from the Royal College of General Practitioners on factors
relating to general practitioner care following the inquest you conducted into the death of Carly Marie
Gordon last year.

| was very sorry to hear that Ms Gordon had died.

On behalf of the College, | set out below a brief description of the remit of the Royal College of General
Practitioners. | also provide some detailed comment on the specific concerns you raise in your report
with regard to the RCGP’s expectations for general practitioner care in the case of a patient presenting
with symptoms such as those of Ms Gordon.

The role of the College

The Royal College of General Practitioners is a registered charity under Royal Charter and is the
largest membership organisation in the United Kingdom solely for GPs. Founded in 1952, it has over
50,000 members who are committed to improving patient care, developing their own skills and
promoting general practice as a discipline. We are an independent professional body with significant
expertise in patient-centred generalist clinical care. Through our General Practice Foundation,
established by the RCGP in 2009, we also maintain close links with other professionals working in
General Practice, such as practice managers, practice nurses and physician assistants.

As well as running the postgraduate Membership examination (MRCGP) which is now required for
doctors to qualify as GPs, the College also provides continuing professional development (CPD) for its
members, and these continuing programmes are also available to non-members of the College.
However, not all GPs are members of the College, and older GPs may never have joined. The General
Medical Council holds the register of all who are considered able to practise as GPs, and itis to the
GMC that revalidated doctors will be notified.

Similarly, it is not for us to comment on the performance of any individual GP and the information set
out below is solely to show you what we provide in the context of training and advice to our Members.

RCGP Education and Training

Currently all doctors wishing to follow a career in general practice in the UK are required to undergo a 3
year programme of vocational training for general practice, based on the College’s GP Curriculum.
(The curriculum forms the foundation for GP training and assessment across the UK, prior to taking the
College’s Membership Examination (MRCGP) and is relevant to GPs throughout their career, including
preparation for revalidation) http:/Avww. regp.org.uk/gp-training-and-exams/gp-curriculum-
overview.aspx

Royal College of General Practitioners 30 Euston Square London NW1 2FB
Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp.org.uk Web www.rcgp.org.uk
Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106

The Royal College of General Practitioners provides guidance to general practitioners on the use of
benzodiazepines and other medication. For your ease of reference, | have attached the 2013
consensus statement which was developed with a range of partner organisations.

In general terms benzodiazepines should be used in lowest possible dose and for shortest possible
time. Should patients find it difficult to withdraw even after 2-4 weeks, guidance is available for
supporting safe withdrawal in support with psychological service and specialist services where needed.

RCGP curriculum currently contains safe prescribing and medicines management approaches and this
is examined routinely as part of the Membership Examination which all doctors take should they wish to
be accredited as a general practitioner. Details of the curriculum can be found at
hte: /Avww.rcap.org.uk/training-exams/gp-curriculum-overview/online-curriculum/managing-complex-
care/3-14-drugs-and-alcohol-misuse.aspx. | can confirm that that this important work is included in the
training of all GPs. Key to the learning are statements in the curriculum as follows:

¢ Appreciate that drug and alcohol use is common the community and that harmful use is often
unrecognised and can take a range of forms (including excessive use, binges, risk-taking
behaviours or dependency).

¢ Understand the presenting signs and symptoms of drug/alcohol misuse, as well as the signs
and symptoms of withdrawal).

* Make sure that repeat prescriptions are monitored for long-term prescribing of addictive drugs
and appropriate action taken if this is happening,

¢ Work in partnership with the wider primary healthcare team including pharmacists, specialist
services, the voluntary and criminal justice sectors.

In addition to my comments above, the RCGP supports a range of other educational initiatives which
support the better prescribing of medication and thus the improved care of patients — these include the
RCGP certificate in the management of drug misuse and also a free to access e learning programme.

Benzodiazepines and other psychotropic drugs can be very effective when they are prescribed
appropriately and in accordance with clinical guidelines but the RCGP is very clear that there can be
difficulties withdrawing them if a patient has been taking them for a period. Overall through our
activities, we would like to see a reduction in the number of prescriptions for benzodiazepines issued
and via initiatives above this is our aim.

| trust that you will find these comments helpful.

Yours sincerely,

Dr Jonathan Leach
Honorary Secretary (elect) of Council

Royai College of General Practitioners 30 Euston Square London NW1 2FB
Tel 020 3188 7400 Fax 020 3188 7401 Email info@regp.org.uk Web www.rcgp.org.uk
Patron; His Royal Highness the Duke of Edinburgh Registered charity number 223106

Addiction to
Medicines
Consensus Statement

January 2013

Medicines have an important role in healthcare.
However, dependence on prescribed and over-the-
counter medicines can occur and can be
devastating to those affected and their families.
Care is needed in the initiation of any drugs that
can lead to dependence and in managing the risk
and development of withdrawal symptoms.

Medicines can be obtained via prescription, over-
the-counter and from illicit and online markets.
Some medicines, such as painkillers, and
tranquillisers like benzodiazepines, carry a known
risk of dependence. Health and social care
professionals across the statutory and voluntary
sector need to work together to prevent addiction
to medicines from occurring and to support all
those suffering dependence and its impact.

In line with the NHS Constitution, all patients
should be treated with dignity and respect and
provided with information to enable them to make
informed decisions about their treatment. This
should include information both about the risk of
dependence, and about how this can be reduced
by taking medicines as prescribed and in ways that
are consistent with the information supplied with
the medicines

Prescribing should be informed by the latest good
quality guidance such as that provided by the
National Institute for Health and Clinical Excellence
(NICE), and where appropriate patients should be
offered appropriate non-pharmacological options
as alternatives or adjuncts to pharmacological
treatments.

Practitioners and patients should reach agreement
on the duration and review of any proposed course
of medication or treatment. Longer term
prescribing can increase the risk of dependence,
and with some medicines, such as tranquillisers
like benzodiazepines, should only be considered
under exceptional circumstances and with regular
review by practitioners with suitable expertise and
understanding of the risks.

Care should be taken when reducing and stopping
any medication because this can cause serious
withdrawal symptoms in some patients and
requires suitable expert support.

Patients should be supported to make informed
decisions about their treatment and this should
include information on the risk of dependence and
withdrawal and how this can be reduced.

10.

11,

12.

13,

14,

15.

16.

17.

Everyone needs to be aware of the risk of
dependence and be proactive to prevent it and
address it when it occurs.

Addiction to medicines is a serious issue that is
best addressed through collaborative action.

Evidence to support prescribing is available
through the web-based NHS Evidence service
managed by NICE (www.evidence.nhs.uk) and the
British National Formulary, which is made available
to ail NHS prescribers.

Non-pharmacological options that can be used as
alternatives or adjuncts to pharmacological
treatment could include physical rehabilitation
advice for pain conditions; and lifestyle advice,
psychological and social therapies and support
interventions for anxiety, depression and pain
conditions.

Regardless of someone’s route into dependence,
there should be a clear pathway to support his or
her individual recovery needs.

Very many of those individuals affected by
dependence on prescription or over-the-counter
medicines require expert treatment and support to
reduce their medication. Withdrawal symptoms for
some medicines can be prolonged and some
individuals require a gradual reduction to achieve
success. The recovery pathway for an individual
needs to take account of the medicine(s) to which
a patient is addicted, any ongoing physical or
psychological health needs, the period of
addiction and the wider support needs of the
patient.

Local areas should ensure that there are services to
respond to the range of local need.

Services dedicated to treating addiction ta
medicines, working alongside other community
well-being services and primary care, can provide
advice, support and individual reduction regimens
that improve patient outcomes.

Through this consensus statement we will strive to
deliver improvements to prevent addiction to
medicines and to support those who have
developed problems to recover.

We the undersigned, representing the Department
of Health, professional groups, Royal Colleges,
specialist services and voluntary organisations
support this joint consensus statement on the
action needed to tackle addiction to medicines.

IRR@E Royal College of
G P General Practitioners

RC?
PSYCH

PSYCHIATRISTS

National Treatment Agency
for Substance Misuse

‘SUBSTANCE MISUSE
MANAGEMENT IN
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National Pharmacy
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Royal College
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THE BRITISH ASSOCIATION OF SOCIAL WORKERS

CENTRE FOR PHARMACY
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THE COLLEGE OF
SOCIALWORK