Natasha Abrahart

Avon and Wiltshire

Mental Health Partnership
NHS Trust

Ms M. E. Voisin, Chief Executive’s Office

Senior Coroner, Area of Avon Coroner's Court, : Bath NHS House
Old Weston Road, . Newbridge Hill
Flax Bourton, Bath
Avon, BA1 3QE
BS48 1UL ° Tel: 01225 362923
22 July 2019

Dear Ms Voisin,

Prevention of Future Death Response

The Trust welcomes the opportunity to respond to the issue you have raised through the Regulation
28 report Prevention of Future Deaths report, in connection with the death of Ms Natasha Abrahart.
We are determined to improve the safety of our services for patients and families following this tragic
death. In response to the report, the Trust has taken the following steps.

We have distributed a Red Top Alert via our Trust-wide alerting system instructing all medical
personnel, all non-medical prescribers, all pharmacists and all team mangers to be ensure that
prescribers follow the NICE Guidance in relation to the prescribing of anti-depressants (CG90), The
instruction includes a requirement to adhere to the guidance and makes clear the responsibility to
communicate effectively with primary care about which individual will undertake the review at seven
days; and that this must be clearly documented. There is a robust auditable system which demands a
response from all the teams circulated in the alert, permitting the identification of any gaps. There will

_ be an obligation for medical leads to discuss this with all their line reports, to ensure effective
communication of this alert.

In addition to the alert, this will also be raised at various fora across the Trust, ensuring that the
learning from this tragic death is shared as widely and comprehensively as possible. These include:

¢ Medical Leads Meeting ~ on the agenda at the next meeting 16th July 2019

e Trust-wide Medical Advisory Group (TMAG) — September 2019

¢ The Learning from Experience Meeting — a meeting that shares learning from experience across
the Trust — on the agenda for the next meeting 17th July 2019

¢ The Medicines Optimisation Group (MOG) — a Trust-wide meeting chaired by the Chief Pharmacist
— on the agenda for the next meeting 23rd July 2019

Please find attached, as an appendix, the Red Top Alert circulated through our patient safety alert
system. .

Chair Trust Headquarters Ading Chiet
Charlotte Hitchings Bath NHS House, Newbridge Hill, Bath BA1 3QE .
; Simon Truelove

| hope the information provided indicates how seriously the Trust has taken the death of Ms Abrahart
and how committed we are to embedding the learning, improving patient safety and reducing
avoidable harm. If there is any further information you require we would be happy to provide this.

Yours sincerely

Simon Truelove
Acting Chief Executive
Avon and Wiltshire Mental Health Partnership NHS Trust

Avon and Wiltshire

Mental Health Partnership
NHS Trust

Reason for issuing this RED Top Alert:

The Trust has received a ‘Prevention of Future Deaths Report’ fol-

lowing a recent inquest which has also been distributed nationally.

The direction from the Coroner requires prescribers who are initiat-
ing antidepressant medication to follow the NICE Guidelines with

respect to antidepressant prescribing (CG90).

The guidelines state in section 1.5.2.7 (CG90):

‘A person with depression started on antidepressants who is con- NICE Guidelines:
Depression in
Adults -
recognition and

_ sidered to present an increased risk of suicide or is younger
than 30 years (bécause of the potential increased prevalence of
suicidal thoughts in the early stages of antidepressant treatment for

this group), should normally be seen after one week and fre- management

quently thereafter as appropriate until the risk is no longer consid- HM Corone 6 Prevent Rue.

ered clinically important.’

The review at seven days does not necessarily need to be under-

taken by the prescriber initiating the treatment.

There must be clear communication between the prescriber and

the reviewing practitioner (whether that be in primary or secondary

care), about who will undertake the review.

This plan and appointment date must be clearly documented in the

electronic patient care record (RiO).

If you require further advice, please contact the Medical Direc-

torate.

Regulation 28 Report from - :

!
|

eZ University of
Wie] BRISTOL

15.07.19

Regulation 28 response

Thank you for giving us the opportunity to review this sensitive issue as a practice, and to
report to you our plans moving forward as an attempt to prevent future deaths from suicide in
our patient population. ,

Background:

The Students Health Service is a GP practice set within the University of Bristol and we serve
a population of around 21,000. The majority of our patients are aged 18-25 years and we see
a high volume of mental] health conditions as part of our daily work as General Practitioners.
From our membership of the Student Health Association we are aware that this is in line with
the experience of other GP practices serving student populations. Our aim as set out in our
Mission Statement is to ‘provide a unique and positive healthcare experience for students and
their dependents’. We are aware of the increased risk of suicide within our population, and
make daily difficult clinical judgements around individual risk and how best to monitor and
support our patients,

- Inquest case:

Natasha Abrahirt was seen by a GP from our practice on 20" April 2018, 10 days prior to her
death. She was not at that time expressing suicidal ideation. She was restarted on an SSRI
(Selective Serotonin Reuptake Inhibitor - Antidepressant) and given a 14 day supply. There
was'a plan to review her at 14 days with an option for her to come back sooner if required.
She was aware she could be seen as an emergency in a same day appointment if necessary.
Natasha was reviewed on 26" April 2018 by the secondary care recovery navigator
responsible for her care, who booked further follow up with her on a weekly basis. She ended
her life 3 days later.

In response:
NICE review (National Institute for Health and Care Excellence)

We have conducted a review of the guidance from NICE, and advice has. been sought from
the team at NICE who are involved in writing new draft guidance which is due to be
published in 2020. Their response is as follows via i Communications
Executive, National Institute for Health and Care Excellence, email 19/06/2019:

{will respond to your questions in reverse order.

1. The evidence for the potential increased prevalence of suicidal thoughts in the early stages
of antidepressant treatment for those younger than 30 years is summarised in section 11.10
of the full guideline (pp.462-465).

Students’ Health Service :

Hampton House Health Centre, St Michaei’s Hill, Gotham

Bristol BS6 BAU UK
Tel: +44 (0)117 330 2577 Fax: +44 (0)117 330 2698

SE 18 ChB, Head of Service -
GS GN, Nursing Team Manager

HER 34 MinstM, Practice Manager bristol.ac.uk/student-health

ee SE

Page 2.

2. The draft version of the updated guideline on depression in adults: treatment and
management that is currently in development (which was made publicly available for
consultation last year, but which is now being amended further) has the following very:
similar recommendation: .

‘When prescribing antidepressant medication for people with depression who are under 30
years or are thought to be at increased risk of suicide:

- see them 1 week after starting the antidepressant medication
- review them as often as needed, but no later than 4 weeks after the first appointment

- base the frequency of review on their circumstances (for example, the availability of
support, break-up of a relationship, loss of employment), and any changes in suicidal
ideation or assessed risk of suicide, '

At this stage I cannot say whether this recommendation will be amended further before the
final publication of the guideline.

In terms of following NICE guidelines, they have always been guidance and not policy or
procedure. The Chair of NICE Sir David Haslam has been quoted as saying “The mantra that
I’ve given in every lecture is that they’re guidelines and not tramlines. Doctors have a
fundamental responsibility to use guidelines with their experience and with patients’
individual needs to get the best possible overlap between patient-centred medicine and
evidence-based medicine. It’s not either/or.”

Local CCG review (Clinical Commissioning Group)

A review of the guidance from the local clinical commissioning group was also undertaken
via the medicines management team at BNSSG CCG - their guidance reads: ;
https://www.bnssgformulary.nhs.uk/includes/documents/Prescribing%20for%20Depression%
20V2%20May!6.pdf

Assessment of suicide risk: Patients considered being at risk of suicide or under 30 years old
should be seen after one week and frequently until risk is considered no longer significant.
All other patients should be seen after 2 weeks, All patients should be considered for drug
and alcohol abuse :

Expert opinion

Thank you to the Coroner for asking for clarification from the expert witness in the case, Dr
HEE 2:0und whether the face to face review at 7 days should be done by a General
Practitioner or by a member of the practice team. He has advised that the assessment of
depressive symptoms ahd suicide risk at this stage could be undertaken by other suitably
trained members of the clinical team e.g nurses, social workers. They could then be supported
by prescribing clinicians if a change needed to be made to antidepressants. This advice is

Page 3.

very welcome as it informs how we respond as a service and how we consider future service
development and staffing. ;

QOF

The current QOF (Quality Outcomes Framework) for.depression states that a depression
interim review should be undertaken at 10-56 days. Having reviewed the guidance around
treatment of depression we would suggest that changing the achievement criteria within this
QOF domain is a potential area for positive change. A change to this time frame might
improve mental health outcomes across primary care, if it were updated at national level to
reflect best practice. We intend to féed this back to our local CCG in the near future.

Current position at Student Health Service:

Every patient is considered on an individual basis and clinical treatment plans are put in place
according to need and perceived risk of suicide and self harm. This includes the use of safety
plans and safety planning apps, both leaflet and text information about emergency
numbers/crisis/Samaritans/who to contact.

We have daily dedicated same day mental health appointments with the duty doctor for
patients with a mental health problem or crisis. We would also see any patient on the day who
felt they needed assessment for their mental or physical health as an emergency. These
emergency mental health appointments are 20 minutes rather than the standard GP
appoiritment of 10 minutes, as we appreciate they may require more time in consultation.

Patients are assessed using a mental health template at first presentation and this includes an
assessment of their perceived suicide risk at the time. Suicidal ideation and self harm are also
routinely asked about at mental health follow up appointments, and at depression medication
or other mental health medication reviews. The template has been further amended to include
a prompt on follow up after commencing SSRI

Any patient thought to be at high or imminent risk of suicide would be referred as an
emergency to Secondary Care Mental Health services using a referral form and a phone call
to the AWP (Avon and Wiltshire Partnership) triage team. We make clinical judgements
around patient safety in the interim, and if necessary can direct the patient to a place of safety
such as the Accident and Emergency department at the hospital.

Patients who ‘do not attend’ (DNA) for appointments routinely have their notes reviewed and
are sent a text with a standard message around missed appointments. If it is clear from the
notes that the patient has mental health concerns and therefore may have missed the
appointment due to their condition deteriorating, then additional efforts are made to contact
the patient — either a tailored text or task sent to the office team to contact the patient to
rearrange the appointment. If there is no response to attempts:to telephone them then a letter
may be sent. If there were significant concerns about the safety of a patient then a welfare
check could be requested from local police. If consent was in place to liaise with University
support services then we would consider contacting them to express our concern. ,

Page 4.

Changes made:

Following the inquest touching upon NA‘s death, we have added an additional field on our
first mental health assessment template regarding SSRI and suicidality: “If SSRI newly
prescribed: counsel re side effects and risk increase suicidality initially: when is follow up?”

{1 response to the concerns expressed within your Regulation 28 report, we have moved
appointments to review patients when starting an SSRI routinely to 1 week, if this is
manageable for the patient, and have this as.a ‘booked’ or ‘known’ appointment in
accordance with NICE guidance. ,

The clinician ideally books the next appointment with the patient at the end of the
constiltation, They place a message on the appointment screen under the follow up
appointment to alert them that this was a mental health review. If the patient cancels it would
be obvious to the reviewing clinician who could follow up appropriately. If the patient
DNA’s then a review of the notes would be undertaken — see above.

Since the inquest we have requested additional funding from the University to advertise for a
permanent Mental Health Nurse to join our eam and this has been agreed. We are currently
working on an advert and job description. The job plan for this member of the team would
include reviewing patients under 30 thought to be at risk of suicide, or starting on SSRI, at 7
days. We are liaising with local partners, mental health advisory service and psychology team

to plan how best to utilise this new resource.

As a practice we are committed to adhering to best practice wherever possible, and to
ensuring that our procedures are ‘compliant with NICE and local guidelines. The inquest
touching Natasha’s death has afforded us an opportunity to review systems in place alongside
the relevant guidance. We are confident that the changes described above are consistent with
local and national guidance. In future we will continue to monitor our systems at the practice
to ensure we are providing care to our patients in accordance with these guidelines.

A
|

BG From Jackie Doyle-Price MP

D ep artm ent Parliamentary Under Secretary of State for Mental Health,

Inequalities and Suicide Prevention

of Health &
i 39 Victoria Street
Social Care ei ret

SW1H OEU

Your Ref: 10686 020 7210 4850

Our Ref: PFD-1178625

Ms Maria Voisin
HM Senior Coroner, Avon
HM Coroner's Court
The Courthouse
Old Weston Road 5
Flax Bourton BS48 1UL ly
July 2019

Mear Wn Vora,

Thank you for your correspondence of 16 May to Matt Hancock and myself about the
death of Ms Natasha Abrahart.

Firstly, I would like to say how sorry I was to read of the circumstances of Natasha’s
death. I can appreciate how distressing her loss, at such a young age, must be for her
family and loved ones and would like to offer my sincerest condolences. We must do
all we can to learn from deeply regrettable incidents such as these to prevent future
deaths.

We recognise the importance of identifying and treating depression in suicide
prevention and welcome the guidelines by the National Institute for Health and Care
Excellence (NICE) on the treatment and management of depression in adults
(Clinical Guideline 90'), and the pathway guidance on anti-depressant treatment in
adults.

I am aware that Clinical Guideline 90 is currently being updated. While it is not
appropriate to pre-empt the results of consultation on the update of the guideline,
NICE advises that the core message of the recommendation around follow up after
ine prescription of antidepressants is likely to remain. —

' https://www.nice.org.uk/guidance/cg90

epee sneer

The latest version of the update that NICE is consulting on reads:

1.4.17 When prescribing antidepressant medication for people with depression
who are under 30 years or are thought to be at increased risk of suicide:
e see them I week after starting the antidepressant medication
e review them as often as needed, but no later than 4 weeks after the first
appointment
e base the frequency of review on their circumstances (for example, the
availability of support, break-up of a relationship, loss of employment),
and any changes in suicidal ideation or assessed risk of suicide. [2018] ?

As you know, this guidance sets out preventative action for people at risk of suicide
and we encourage the NHS to implement these guidelines. Clinical guidelines
represent best practice and should be taken fully into account by clinicians.

You may wish to note that in October 2018, Health Education England (HEE)
launched a suite of four Self Harm and Suicide Prevention Frameworks. The
frameworks describe some of the important things that a skilled professional, or
member of staff, needs to have to be able to support people who self-harm or have
suicidal thoughts.

These frameworks highlight the importance of health professionals having the
required knowledge of pharmaceutical interventions and, for those with prescribing
rights, knowledge of the potential adverse effects of antidepressant medication,
including possible increases in suicidal thoughts and behaviours. The frameworks
also highlight the importance of knowledge of national guidance, including NICE
guidelines, for the treatment of people who self-harm and/or are suicidal that include
recommendations regarding the role of medication.

HEE is also undertaking a scoping exercise of existing suicide training provision to
identify gaps, using the competency frameworks, to enable the development of an
online compendium of training which will be freely accessible to all health
professionals.

As the Minister for Universities, Chris Skidmore MP, and I advised when we jointly
responded to you on a recent Prevention of Future Deaths Report issued following the
inquest into the death of Mr Benjamin Murray, mental health and suicide prevention
are key Priorities for this Government. -

2 https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0725/documents

This Government has set out an ambitious programme of work to reduce suicides,
including actions being taken to improve the mental health of university students.
This ambition is set out in the first cross-Government Suicide Prevention Workplan
published in January 2019°.

Several initiatives are being undertaken to promote best practice in the higher
education sector and to support universities to adopt mental health as a strategic
priority. In summary, this includes:

e Guidance on measures to help prevent suicide, ‘Suicide-Safer Universities”,
2018. All universities are expected to actively engage with the guidance to
improve mental health support and reduce suicide risks amongst their student
population;

¢ Funding investment in 10 projects encouraging higher education providers to
find new ways of combating student mental health issues, including the
development of links between higher education providers and local primary
care and mental health services®. Outcomes will be widely communicated
across the sector;

e £1million extra funding announced by the Prime Minister in June 2019 for
proposals to promote partnership working between the health and education
sectors®;

e The University Mental Health Charter’, supported by the Government and led
by the higher education sector to drive up standards in promoting student and
staff mental health and wellbeing; and,

e Launch of the Education Transitions Network in March 2019° by the
Department for Education which will be developing a strategic approach to
supporting students when starting university and will provide advice on how
universities can get better at involving support networks at an early stage
when students are struggling.

3 https://www.gov.uk/government/publications/suicide-prevention-cross-government-plan

4 https://www.universitiesuk.ac.uk/policy-and-analysis/reports/Pages/guidance-for-universities-on-preventing-student-
suicides.aspx

5 https://www.officeforstudents.org.uk/news-blog-and-events/press-and-media/innovation-partnership-and-data-can-
help-improve-student-mental-health-in-new-14m-drive/

6 https://www.gov.ul/goverment/news/pm-lainches-new-mission-to-put-prevention-at-the-top-of-the-mental-health-
agenda. ~ : . 8 :

7 https://www.gov.uk/government/news/new-package-of-measures-announced-on-student-mental-health

8 https://dfemedia. blog. gov.uk/2019/03/07/thursday-7-march-2019-university-mental-health/

I hope this response demonstrates the Government’s commitment to supporting
student mental health and wellbeing and to the prevention of suicide.

E DOYLE-PRICE