Matthew Evans

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne
NE1 4PA 

Private and Confidential 

Dr Karen Henderson 
HM Assistant Coroner for Surrey 
HM Coroner’s Court 
Station Approach 
Woking 
Surrey
GU22 7AP 

21 July 2022 

Care Quality Commission 

Dear HM Coroner 

Prevention  of  future  death  report  following  inquest  into  the  death  of 
Matthew John Evans. 

Thank you for sending CQC a copy of the prevention of future death report 
issued following the sad death of Matthew John Evans.  I would like to extend our 
condolences to Mr Evans’ family. 

Following receipt of the report, CQC contacted Farnham Park Health Group, the 
provider of The Ferns Medical Practice, to request written confirmation and 
evidence of the action they have taken to date in light of Mr Evans’ death. We 
also requested any additional action they intend to take in response to the 
prevention of future death report. 

In response to our request, we have received evidence of a significant event 
analysis, completed on 31 May 2022, and a detailed action plan, laying out the 
steps the provider is actively implementing in response to Mr Evans’ death. Out 
of the 10 actions identified, the provider was able to demonstrate seven actions 
have already been completed to date, and the remaining three remain in 
progress, mainly due to external resources being required. 

We are satisfied, at this point, that the circumstances surrounding Mr Evans’ 
death were a specific case and not indicative of widespread poor care on the part 
of the provider. Whilst we have concluded that improvements could have been 
made in the care and treatment provided to Mr Evans, it was not unsafe. We are 
pleased to see the provider has identified areas of improvement in its care and 
treatment, and we are assured that the actions taken will protect others using the 
service from harm. At this stage we have decided not to instigate any further 
action. However, we will continue to regularly monitor the provider and, where 

1 

 
 
 
 necessary, take regulatory action to ensure patients are receiving a safe service. 

As you may be aware, CQC can only take regulatory action against a registered 
manager or a registered provider, but not when failings of an individual have 
been identified. 

Please  also  be  advised  our  records  showed  we  were  not  notified  of  Mr  Evans’ 
death  by  the  registered  provider,  as  was  legally  required.  This  failure  to  report 
was  immediately  raised  with  the  provider  and  we  have  since  received  this 
information.  In accordance with our regulatory processes, consideration will now 
be  given  as  to  whether  further  action  is  needed  to  address  this  breach  of 
regulation for failing to notify us in a timely way. 

Please do not hesitate to contact me should you require any further information. 

Yours sincerely 

Inspection Manager
Thames Valley
Primary Medical Services
Care Quality Commission 

2

From Neil O’Brien MP 
 Parliamentary Under Secretary of State for Primary Care and Public Health  

Dr Karen Henderson 
HM Coroner’s Court 
Station Approach 
Woking 
GU22 7AP 

Dear Dr Henderson, 

12 December 2022 

Thank you for your letter of 18 May 2022 about the death of Matthew John Evans.  I am 
replying as the Minister with responsibility for Primary Care.     

Firstly, I would like to say how deeply saddened I was to read of the circumstances of Mr 
Evans’s death.  I can appreciate how distressing his death must be for his family and those 
who knew and loved him and I offer my heartfelt condolences.  The circumstances your 
report describes are very concerning and I am grateful to you for bringing these matters to 
my attention.  

In preparing this response, Departmental officials have made enquiries with NHS England 
and the Care Quality Commission (CQC). 

Patient safety is a top priority for the government and the health service, and we want 
everyone to receive the care they need. 

I understand that the CQC, NHS England and NHS Frimley Integrated Care Board have 
responded to you directly to outline their ongoing implementation of actions following your 
report.  I am also pleased to note that Farnham Park General Practice undertook 
significant event analysis that concluded on 31 May 2022, and have created a detailed 
action plan in response to Mr Evans’s death. 

As noted by NHS England, there are several educational resources and guidance 
documents relating to the assessment and treatment of depression that are regularly 
reviewed and accessible to clinicians.  These include National Institute for Health and Care 
Excellence (NICE) guidance, which details possible adverse effects of prescribing 
mirtazapine, Clinical Knowledge Summaries and the British National Formulary.  

General Practitioners are responsible for ensuring their own clinical knowledge remains 
up-to-date and for identifying learning needs as part of their continuing professional 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 development.  This activity should include taking account of new research and 
developments in guidance, such as that produced by NICE, to ensure that they can 
continue to provide high quality care to all patients, including those suffering from mental 
health difficulties.  

In addition, all UK registered doctors are expected to meet the professional standards set 
out in the General Medical Council’s (GMC) Good Medical Practice.  In 2012, the GMC 
introduced revalidation, which supports doctors in regularly reflecting on how they can 
develop or improve their practice.  It gives patients confidence that doctors are up to date 
with their practice and promotes improved quality of care by driving improvements in 
clinical governance. 

Furthermore, the training curricula for postgraduate trainee doctors is set by the relevant 
medical Royal College and has to meet the standards set by the GMC.  Whilst curricula do 
not necessarily highlight specific conditions for doctors to be aware of, they instead 
emphasise the skills and approaches that a doctor must develop in order to ensure 
accurate and timely diagnoses and treatment plans for their patients.   

During the pandemic, GP practices made use of remote consultations, including telephone 
calls, to minimise infection risks and prioritise care.  While telephone and remote 
consultations can be more flexible and convenient, they are not right for all patients or in 
all circumstances.  NHS England guidance is clear that patients’ input into choices about 
appointment mode should be sought and practices should respect preferences for face-to-
face care, unless there are good clinical reasons to the contrary.  We expect patients to 
experience the same high quality of care regardless of how they access their GP surgery. 

You also raised concerns about the lack of policy to assist GPs with prescribing 
Mirtazapine, antidepressants and anxiolytics.  The decision to prescribe a particular drug is 
a clinical one and should be based on the patient’s medical needs.  Decisions about what 
medicines to prescribe are made by the doctor or healthcare professional responsible for 
that part of the patient’s care and prescribers are accountable for their prescribing 
decisions, both professionally and to their service commissioners.  It is for the GP or other 
responsible clinician to work with their patient and decide on the course of treatment, with 
the provision of the most clinically appropriate care for the individual always being the 
primary consideration.  

Clinicians are responsible for making prescribing decisions for their patients, taking into 
account best prescribing practice and the local commissioning decisions of their respective 
integrated care boards.  They are also expected to take account of appropriate national 
guidance on clinical and cost effectiveness, and are accountable for their prescribing 
decisions, both professionally and to their service commissioners. 

In addition, NICE guidelines provide recommendations on best practice in terms of both 
the effectiveness and cost-effectiveness of interventions and services.   NICE also have 
guidelines available on treatment and management on anxiety and depression. 

NICE guidelines describe best practice, and the Government expects NHS commissioners 
to take them into account in designing services that meet the needs of their local 
populations.  It is however important to note that NICE guidelines are not mandatory and 
do not override a clinician’s responsibility to make decisions appropriate to individual 
patients. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 I hope this response is helpful. Thank you for bringing these concerns to my attention. 

NEIL O’BRIEN MP

IN WOKING CORONER’S COURT 

BEFORE HER MAJESTY’S CORONER FOR SURREY 

THE INQUEST TOUCHING THE DEATH OF MATTHEW EVANS 

___________________________________________ 

Response to Regulation 28 

___________________________________________ 

1.  H.M. Coroner for Surrey, 

, has made a Regulation 28 Report – Action 

to prevent deaths – dated 18 May 2022 (“the Regulation 28 Report”) concerning the death 

of Mr Matthew Evans (“the Deceased”). 

2. 

 and the Farnham Park GP Practice (“the Practice”) respond to the Regulation 28 

Report in accordance with Regulation 29 of the Coroners Investigations (Regulations) 2013 

(“the Response”). 

3.  The Partners at the Practice were awaiting the outcome of the Inquest before undertaking 

a Serious Event Audit (“the SEA”). The Practice Partners considered it appropriate that the 

SEA  took  place  when  it  was  possible  to  maximize  the  number  of  clinicians  attending  the 

audit meeting. The Practice conducted a SEA on Tuesday 31 May 2022. There having been 

delays  due  to  bereavement,  sickness,  leave  and  the  various  Bank  Holidays  which 

interrupted  the  Practice  working  timetable,  which  impacted  on  the  availabilities  of  the 

various members of Practice team. Six clinicians participated in the SEA, including 

. 

4. 

 presented the case to all the attendees at the SEA – including the history and his 

consultations with the Deceased. The Clinicians also went through H.M. Coroner’s Inquest 

findings and the outcome of the Inquest, and the Regulation 28 Report. 

5.  This is the Response of 

 and the Practice to the concerns raised in the Regulation 

28 Report concerning both. 

“The  GP  was  not  sufficiently  proactive  with  multiple  lost  opportunities  to  provide  better  care  and 

support for Matthew.” 

6. 

7. 

  does  not  agree.  Rather  than  give  a  sleeping  tablet  that  would  not  solve  the 

Deceased’s problem on the first consultation, he suggested alternatives. 

  focus  shifted  to  a  depression  and  anxiety  upon  more  information  becoming 

available.  The  prescription  of 

  is  recognized  to  treat  depression  and  anxiety, 

and also sometimes causes drowsiness which 

 hoped might help the insomnia as 

well. 

8.  Treatment with 

 and high intensity CBT fell within the NICE guidelines. 

9. 

 was not in control of when the Deceased was progressed from normal CBT to high 

intensity CBT, he could only refer to the service. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
   
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 10.  The Deceased did not come close to a referral to the urgent assessment unit. 

11. 

 a clinical psychologist, gave evidence for TalkPlus. H.M. Coroner invited 

on a number of occasions to conclude that the Deceased should have been referred 

onwards to secondary mental health services/ the Single Point of Access. 

 did not 

agree, but she thought in hindsight perhaps the Deceased could have been stepped-up to 

high intensity CBT slightly earlier. 

12.  In cross-examination 

 confirmed: 

(i) 

  agreed.  that  everyone  who  encountered  the  Deceased  at  TalkPlus 

thought he was an appropriate patient for CBT. 

(ii) 

It  was  not  unusual  to  have  someone  with  the  Deceased’s  high  scores  for 

depression  and  anxiety  in  the  service.  Neither  was  it  unusual  for  someone  to 

struggle with CBT at first, and then succeed when stepped up to high intensity CBT. 

(iii) 

The  Deceased’s  risk  remained  low  throughout.  He  had  no  specific  plans,  and  a 

protective factor in his partner. 

(iv) 

TalkPlus  could  and  often  did  refer  onwards  to  the  Single  Point  of  Access  for 

secondary care mental health services. The Deceased did not meet the criteria for 

onward  referral.  The  criteria  would  involve  someone  who  had  a  plan  to  commit 

suicide or  did not  have any protective  factors. That  was based  on feedback from 

the Single Point of Access when refusing referrals. 

(v) 

There were a lack of options in secondary care for psychological therapy and that 

was a subject 

 had regularly talked to the CCG about. 

13. 

  has  identified  a CPD  course concerning  Mental  Health  –  recognize  suicide risks, 

which he shall be attending by way of reminder and on-going professional development. 

14.  He will be reflecting on the care and concerns raised by H.M. Coroner in his Appraisal and 

Personal Development Plan. 

The  GP  did  not  undertake  a  mental  health  assessment  to  assess  the  severity  of  Matthew’s 

difficulties and to ascertain whether further support or referral to secondary mental health care were 

indicated  in  any  of  the  four  telephone  consultations.  He  did  not  ask  or  document  at  any  time  if 

Matthew had any suicidal ideation or acts of self-harm. 

15.  Whilst 

  did  not  use  the  PHQ9  or  GAD7  questionnaires,  he  undertook  a  risk 

assessment  by  asking  about  suicide  intent  and  deliberate  self-harming  activities  or 

thoughts. 

16. 

 did not document the risk assessments he made during the consultations. However, 

he asked  about  suicidal ideation  on 2  and  9 June 2021. 

  did not agree  that  those 

discussions did not happen. He accepts he did not record this. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
   
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 17. 

 has identified training provided by MDU Serviced Limited which he shall attend, on 

record  keeping,  the  date  for  the  next  course  is  yet  to  be  confirmed.  He  has  already 

refamiliarized himself with the GMC Good Medical Practice guidance on record keeping by 

way of reminder of the standards expected. 

18.  PHQ9/GAD7  questionnaire  will  now  be  sent  to  patients  to  complete  ahead  of  their 

consultations.  Scores  will  be  written  directly  into  EMIS  Web  so  available  during  the 

consultation with the patient. 

19.  Safety netting advice must be documented in EMIS Web when given. 

20.  Accrufix Template created and circulated to all clinicians on where to find GAD & PHQ-9 to 

detect patient’s anxiety and symptoms. 

21.  See the Action Plan attached. 

The GP did not offer a face-to-face consultation or arrange a follow up appointment. 

22.  No  face-to-face  consultation  was  offered,  but  this  was  in  the  context  of  the  GPs  at  the 

Practice working in the  midst of  a pandemic, them having been advised to  avoid  face-to-

face consultations, where possible, in order to reduce footfall. 

23. 

  (TalkPlus)  gave  evidence  about  face-to-face  consultations  and  that,  perhaps 

surprisingly,  the  evidence  did  not  suggest  that  face  to  face  therapies  were  any  more 

effective than telephone. She herself had been surprised during the pandemic at how well 

someone could be assessed by telephone. 

24. 

  and  the  Practice  have  agreed  that  patients  presenting  with  new  mental  health 

issues,  are  to  be  offered  face-to-face  appointments.  This  policy  was  introduced  with 

immediate effect from the date of the SEA. 

25.  The Practice will review patient follow up timescale and GP should book them in rather than 

ask patient to call in as they may not be able to get through. 

26.  See the Action Plan attached. 

The  GP  declined  to  prescribe  Zopiclone  and  whilst  he  referred  Matthew  to  the  benefits  of 

Melatonin he did not offer a prescription. 

27. 

 did not offer a prescription for 

 to the Deceased when he suggested its 

use, as the Deceased wanted to think over its use, which was also the case when 

again suggested the use of 

 in a later consultation. 

He  prescribed 

  having  not  done  so  before  for  someone  in  Matthew’s  position  on  a 

background of having no post graduate qualifications in mental health. Furthermore, he did not 

document any warning of the possible side-effects of this drug including the possible increased 

risk of suicidal ideation with commencing the drug. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 28.

 has prescribed 

before. He was asked by H.M. Coroner whether he had 

ever  prescribed 

 to a  middle-aged  man experiencing  mental health  issues  for 

the first time before. 

 confirmed this was the first time he had initiated the prescription 

of this medication to someone not in a care home (i.e., not elderly). 

29.  At  the  SEA  the  Practice  concluded,  following  full  consideration,  that 

  choice  of 

  was  appropriate  given  that  the  Deceased’s  original  primary  cause  for  him 

contacting the Practice was his insomnia. 

30. 

 wrote to the CCG prescribing lead on 22 May 2022 and asked as to whether there 

is any policy regarding the prescription of 

 [see Action Plan attached]. She 

replied on 26 May 2022 that: 

‘there  is  no  CCG  guidelines  except  to  prescribe  in  line  with  the  relevant  NICE 

recommendations,  BNF  information  and  NICE  CKS  guidance.  The  first  line  option  for 

depression would be an SSRI  but  where an SSRI  is  not suitable, 

 may be an 

alternative option to consider’. 

31. 

 repeats and relies upon the comments in paragraphs 16 to 20 above. 

“It is unclear whether the GP had read the letters from TalkPlus.” 

32.  An Audit of the GP computer system was completed on 31 May 2022. This confirms 

read two of the letters from TalkPlus within 24 hours of receipt, one was received and read 

within  3  working  days.  There  is  a  History  Trail  in  Docman  which  automatically  records 

receipt/read for every document received [see Action Plan attached]. 

33.  The Audit results, analysis and actions recommended have been shared with the Clinical 

Governance (Lead, Group) of the Practice. 

34.  See the Action Plan and SEA Report attached. 

He did not ask permission as to whether it was possible to inform or involve Matthew’s partner 

and family in his on-going care.” 

35.  Going forward in appropriate situations 

 will seek permission to contact and inform 

family members. 

No policy was provided to assist GP’s with prescribing of 

 antidepressants and 

anxiolytics in general practice. 

36.  The Practice repeats and relies upon the response at paragraph 30 above. 

37.  NICE Guidelines on 

 prescribing, treatment and information have been 

circulated. Further guidelines sought from the CCG about depression and anti-depressant 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 prescribing. All discussed and circulated on 20 June 2022 to all clinicians including 

Frimley ICS Medicines Optimization Board prescribing guidelines. 

38.  The Practice will conduct an Audit of patient 

 use by August 2022. To present 

audit results and identity if there is/are action/s required in relation to patient safety i.e. 

patient education regarding the use of the drug, follow-up to check p[patient remined safe 

in taking this drug, and does or has the patient required secondary referral to be 

supported by the community mental heath team. 

39.  Also see SEA Report and Action Plan attached. 

There is no confirmation electronic letters have been signed as read and acted upon by the 

relevant GP. 

40.  The Practice repeats and relies upon the responses at paragraphs 32 – 34 above and the 

SEA Report and Action Plan attached. 

No evidence was provided with regard to ongoing training in mental health for GP’s. 

41.  The  Practice  is  liaising  with  mental  health  providers  to  arrange  in-house  training.  The 

Practice contacted Spires Clare Park, a local hospital which provides private health care on 

31 May 2022 to organise Mental Health training. Spire Clare Park have a programme where 

consultants of various specialties provide educational teaching/meetings for local GPs,. No 

consultant psychiatrist was available to offer training. The Practice communicated with the 

mental health lead at the CCG on 21 June 2022 regarding mental health pathways and the 

Primary Care Network Additional Roles Reimbursement Scheme roles and Cardinal Clinic 

(a private medical hospital which also provides educational programmes for GPs but they 

were not able to offer training. A clinical psychologist has been identified who will provide 

mental  health  training,  which  will  occur  on  a  date  to  be  fixed  when  maximum  number  of 

clinicians are available to attend. It is hoped this will be sometime during the next couple of 

months but certainly before the end of the autumn session. 

Matthew’s death was not investigated or reviewed by the GP practice with the consequence no 

learning  points  have  been  considered  or,  if  necessary,  changes  implemented,  giving  rise  to 

concern over the lack of robust clinical governance procedure within the practice. 

42.  This significant  event  was  discussed  on  18  June 2021,  two  days  after  it  happened  at  a 

Partners  practice  meeting.  Further  discussions  were  to  be  arranged  following  the 

Coroner’s  Report.  When  the  Report  was  available,  the  Practice  Manager  arranged  a 

Significant  Event  Analysis,  inviting  all  clinical  staff  members.  The  date  for  maximum 

attendance was chosen as 31.05.2022. 

43.  The SEA took place on 31.05.2022. See SEA Report and Action Plan attached. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 44.  The Practice has shared the findings of the SEA with all staff at the practice, the CCG and 

CQC. 

45.  Going forward, as part of the Practice’s Clinical Governance Policy, it was further agreed 

that unexpected deaths will be discussed at the Practice Clinical Meetings’ Meetings which 

are held every week and attended by the GP clinicians and Partners.

4 August 2022 

In reply please quote: CW/C1-3576744640 

Private: Addressee Only 
Ms Sarah Church 
HM Coroner Surrey 
Surrey 

Dear Ms Church 

We have finished our review of your concerns regarding 
touching on the death of Matthew John Evans Regulation 28 Report) 

 (Inquest 

We have now completed our enquiries and the evidence we gathered has now been 
considered by one of our decision makers, known as an assistant registrar (AR). 

The AR is assured that the matters contained in your complaint do not raise concerns that 

 poses either a risk to patients or undermines the public’s confidence in 

doctors. Although we do not need to investigate further, we will share your concerns with 
the doctor’s responsible officer and ask the doctor to discuss it with their appraiser as part 
of their revalidation. 

Thank you 

Thank you for bringing these concerns to our attention. If you have any questions about 
the process so far, please contact me and I will do my best to help. 

Yours sincerely 

Investigation Officer 

Email: 
Website: www.gmc-uk.org 
Telephone:

Ms Karen Henderson 
HM Coroner’s  Court, 
Station  Approach, 
Woking 
GU22 7AP 

Dear Ms Henderson 

National Medical  Director 
NHS England 
Wellington  House 
133-155  Waterloo  Road Road 
London 
SE1 8UG 

Re: Regulation  28 Report to Prevent Future Deaths – Matthew John Evans who 
died on 16 June 2021. 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”)  dated 18 
May 2022 concerning  the death of Matthew Evans on 16 June 2021.  I would  like to 
express my deep condolences  to Matthew’s  family. 

I note the inquest  concluded  Matthew’s death  was a result of: 

1a. Suspension 

Following  the inquest,  you raised concerns in your Report regarding: 

1.  The actions  of the General Practitioner 

The GP was not sufficiently proactive with multiple  lost opportunities  to provide better 
care and  support  for Matthew. The GP did not undertake  a mental health 
assessment  to assess  the severity of Matthew’s difficulties and to ascertain  whether 
further support  or referral to secondary mental health  care were indicated  in any  of 
the four telephone  consultations.  He did  not ask or document at any  time if Matthew 
had any  suicidal ideation  or acts of self-harm. The GP did not offer a face-to-face 
consultation  or arrange a follow up appointment.  The GP declined  to prescribe 

  and whilst  he referred Matthew to the benefits of Melatonin  he did not 

  having not done  so before for 
offer a prescription.  He prescribed 
someone  in Matthew’s position  on a background of having no post  graduate 
qualifications  in mental health.  Furthermore,  he did not document any warning  of the 
possible  side-effects of this drug including  the possible  increased  risk of suicidal 
ideation  with commencing the drug. It is unclear whether  the GP had  read the letters 
from TalkPlus.  He did  not ask permission  as to whether  it was possible  to inform or 
involve Matthew’s partner and family in his on-going  care. 

2.  The actions  of the General Practice 

No policy was provided to assist  GP’s with prescribing  of 

electronic letters have been  signed  as read and acted upon  by the relevant GP. No 
evidence was provided  with regard to ongoing  training  in mental health  for GP’s. 

in general  practice. There is no confirmation 

 
 
 
 
 
  
 
 
  
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
   
 
 
 
 
 
 
 
 
 
 
 
   
  
 
 
 
 
 Matthew’s death was not investigated  or reviewed by the GP practice with the 
consequence  no learning  points have been considered  or, if necessary,  changes 
implemented,  giving  rise to concern over the lack of robust  clinical governance 
procedure  within the practice. 

The Frimley Integrated  Care Board (ICB) have shared their response  with me. The 
NHS Frimley ICB will be carrying out a number of actions following the inquest.  I will 
not repeat  these,  however would like to reassure  you that the ICB will provide 
confirmation to the Regions of their  completion.  An NHS England  Region  is an 
integral part of NHS England.  It is a sub-division  of NHS England’s  Operations  and 
Information Directorate,  and is responsible  for the quality, financial and operational 
performance of all NHS organisations  in their region. 

In response  to receiving your Report, NHS England  has  taken action  to refer 
Farnham Park GP to NHS England South East region’s  Professional  Standards 
team, under NHS England’s  ‘Responding  to Concerns’  framework and any  additional 
actions arising  that are required to address the  concerns of the coroner, will be 
overseen  and followed though by the NHS England  South East region’s  Professional 
Advisory Group. 

The NHS England Kent, Surrey and Sussex regional  team will be convening a 
Performance Advisory Group (PAG) as part of NHS England » Responding  to 
concerns procedures.  A PAG is a  small, local panel  of people  who are tasked  with 
carrying out or directing the scope of investigatory  and advisory work relating  to 
concerns about  doctors on the Performers Lists.  Any additional  actions arising to 
address  concerns of the practitioner  will be considered  further in the PAG. 

I have pulled  out the main points from the concerns raised regarding  the actions of 
the General  Practitioner  and the General Practice. I am unable  to comment on the 
specific details  of the actions of the GP and practice. However, I have highlighted 
guidance  that relate  to these points. 

1.  The actions  of the General Practitioner 

a) The GP did not undertake a mental health  assessment  to assess  the severity 
of Matthew’s difficulties 

There are several  educational  resources and guidance  documents relating  to the 
assessment  and treatment  of depression  that are accessible  to clinicians. 

The National  Institute  for Clinical Excellence (NICE) supports  clinicians with Clinical 
Knowledge  Summaries in many areas including  assessment  and  treatment of 
depression.  This guidance  also covers the prescribing  of mirtazapine  and 
antidepressants  and anxiolytics. 

NICE have also recently updated  their  guidance  on “Depression  in adults:  treatment 
and management  guidance”(29th  June 2022):  The latest  draft of this update is 
available  to view at https://www.nice.org.uk/guidance/indevelopment/gid-
cgwave0725/documents. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 More detailed  guidance  on the prescribing  and use of specific antidepressants 
including  Mirtazapine  is published  by the British  National  Formulary (see 
https://bnf.nice.org.uk/drugs/mirtazapine/)  and also as part of the SmPC available  at 
https://www.medicines.org.uk/emc/medicine/26391/SPC/Mirtazapine+30mg+Tablets 

RCGP position  statement  on mental health in primary care - September 
2017  advises: 

“common  mental  health  problems  are managed  using the approach recommended 
by NICE. GPs should manage  patients  using a combination  of medication, 
psychological therapies,  support groups,  befriending,  rehabilitation  programmes, 
educational  and employment  support services and  referral for further assessment 
and interventions  in secondary care if needed. 

GPs should be aware of the issues around  confidentiality  and suicidal ideation.  In 
line with good  practice, practitioners  should routinely  confirm with people  whether 
and how they wish their family and friends  to be involved in their  care generally” 

b) The GP did not offer a follow up appointment 

The Quality and Outcomes Framework (QOF) indicator  (DEP003) for depression  for 
2021/22  states  the following requirement: 

The percentage  of patients  aged 18 or over with a new diagnosis of depression  in 
the preceding  1 April to 31 March, who have been reviewed not earlier  than  10 days 
after and not later  than 56 days after the date of diagnosis 

This recommendation is based  on NICE guidance on depression  in adults.  It 
recommends that patients  with mild or moderate depression  who start 
antidepressants  are reviewed after one week if they are considered to present  an 
increased  risk of suicide  or after two weeks if they are not considered  at increased 
risk of suicide.  Patients  are then  re-assessed  at regular  intervals determined by their 
response  to treatment and whether  or not they are considered to be at an increased 
risk of suicide. 

c) The GP did not offer a face-to-face  consultation 

During the Covid-19  pandemic, a greater  number of consultations  took place 
remotely with the aim of keeping patients  and staff as safe as possible  from Covid-
19. This was in line  with the NHS England  guidance  at that  time: 

https://www.england.nhs.uk/coronavirus/documents/advice-on-how-to-establish-a-
remote-total-triage-model-in-general-practice-using-online-consultations/#intro 

However, on 13th  May 2021  NHS England  wrote to GP practices with information 
about  an updated  version of the standard  operating  procedure  (SOP) to support 
restoration  of general  practice services  SOP (england.nhs.uk).  This was in 
anticipation  of government changes to social distancing  from 17 May 2021.  This 
advised  that GP practices must all ensure  they are offering face-to-face 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 appointments  and that  patients and clinicians have a choice of consultation  mode. 
The full SOP was published  on 19 July 2021  . 

2.  The actions  of the General Practice 

a)  No policy  was provided  to assist  GP’s with prescribing  of Mirtazapine and 

antidepressants  and anxiolytics  in general  practice 

As stated  above, there are several  guidance  documents to support  clinicians in the 
assessment  and treatment  of depression.  These  include  NICE guidance,  Clinical 
Knowledge  Summaries and  the British National  Formulary. 

GPs undergo  training  in mental health  as part of the GP trainee  scheme as well as 
during  ongoing  continuing  personal  development  (CPD). Ongoing  learning  is 
expected as part of the GMC's appraisal  and  revalidation  processes.  As a result, 
GPs are usually  experienced  with the assessment  and treatment  of depression. 

b)  No confirmation  electronic  letters have been signed as read and acted upon 

by the relevant  GP 

Incoming correspondence  should be read by either  the appropriate  GP or another 
member of the primary care team. In relation to managing correspondence  and test 
results,  the Care Quality Commission  updated  its guidance  on 24th  May 2022: 

Robust practice protocols and  standardised  processes can protect patients. We 
expect to see that  practices have an agreed and documented  approach that every 
member  of the practice team understands.  Practices can develop  their own systems 
and protocols to safely manage  test results. They must be able to demonstrate  their 
effectiveness. 

To free up clinical time not all correspondence  needs  to be seen by the GP but can 
be managed  by trained non-clinicians  when appropriate. 

c)  Matthew’s death was not investigated  or reviewed by the GP practice with 

the consequence  no learning  points have been considered  or, if necessary, 
changes  implemented,  giving rise to concern  over the lack of robust 
clinical  governance procedure  within the practice. 

National  guidance for reporting  and investigating  serious  incidents is available 
online:  Guide  for general  practice staff on reporting  patient  safety incidents  to NRLS 
(2015)  and  Serious Incident  Framework 2015. There is a clear definition  of what 
constitutes  a serious  incident  which includes acts or omissions  in care that result  in; 
unexpected  or avoidable  death (including  suicide),  and unexpected  or avoidable 
injury resulting  in serious harm. 
Once a serious incident  is reported, NHS commissioners have responsibility  to 
quality  assure  the robustness  of their providers ’serious  incident  investigations  and 
the action plan  implementation.  Commissioners  are responsible  for oversight  and 
closure  of serious  incidents from all commissioned  providers;  these include  acute, 
community, mental health,  primary care, and independent  providers 

 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Primary care (including  GP practices)  must have effective clinical governance,  which 
includes discussions  on unexpected deaths  and significant  events, both  positive and 
negative. 

•  See GP mythbuster 3: Significant Event Analysis (SEA). 
•  See GP mythbuster 65: Effective clinical governance arrangements in GP 

practices | CQC Public Website. 

Future actions 

The NHS patient  safety strategy  published  in 2019,  set out goals  for patient  safety 
improvement in incident  recording, incident  response  and primary care.  The NHS 
England  » Learn from patient  safety events (LFPSE) service was launched in July 
2021,  enabling  primary care to record incidents  and other safety events via the new 
service.  As LFPSE is rolled out across the NHS in 2023,  all providers will be 
expected to record their  incidents via this system. 
Alongside  changes to incident recording,  the NHS England » Patient  Safety Incident 
Response  Framework PSIRF) outlining  how providers should respond  to patient 
safety incidents  and how and  when a patient  safety investigation  should be 
conducted,  will commence in Summer 2022.  Initially,  the PSIRF implementation  is 
focused in secondary care and pilots  will be undertaken  in primary care after this to 
develop  the framework effectively for primary care. The PSIRF promotes systematic, 
compassionate,  and proportionate  responses  to patient  safety incidents,  anchored in 
the principles  of openness,  fair accountability,  learning  and  continuous  improvement 
– and with the aim of learning  how to reduce risk and associated  harm. The PSIRF 
recognises  that meaningful learning  and improvement following  a patient  safety 
incident  can only be achieved if supportive  systems and processes  are in place. The 
PSIRF supports  development  of a patient  safety incident  response  system that 
prioritises  compassionate  engagement  and involvement of those affected by patient 
safety incidents. 

This report will be provided to the Regional Mortality Boards so that  they may share 
it with all ICBs to ensure that they are able to learn from this event. 

Thank you for bringing  these important  patient  safety issues  to my attention  and 
please  do not hesitate  to contact me should  you need any  further information. 

Yours sincerely, 

National  Medical Director 
NHS England

Headquarters 
King Edward VII Hospital 
St. Leonards Rd,  
Windsor  
SL4 3DP 

Tel: 

6th July 2022 

 Re: The Inquest Touching the Death of Matthew John Evans  
        A Regulation 28 Report – Action to Prevent Future Deaths 

Private and confidential 

Dear Dr Henderson 

Introduction 

I am responding to the Regulation 28 Report –Action to Prevent Future Deaths on behalf of NHS 
Frimley ICB following the death of Matthew Evans. I would like to extend our condolences to Mr 
Evans’ family.  

Following the inquest, you raised a number of concerns with regard to the actions of the General 
Practitioner, the General Practice and TalkPlus. I am writing to provide details of the actions that the 
NHS Frimley ICB has undertaken, and is proposing to undertake, in response to your concerns.  

There is a preliminary point that I would like to make to provide some context to this response. The 
actions that the NHS Frimley ICB has or will be taking involve engagement with all the practices in 
its area. In turn, this means that it is not always possible to provide precise dates when actions have 
been carried out and I have accordingly referred below to actions being undertaken within calendar 
months rather than on specific dates. 

Sharing of information/enhanced education 

The NHS Frimley ICB will be carrying out a number of actions following the inquest. These include 
sharing  the  concerns  raised  with  all  GP  practices  in  the  Frimley  area.  The  learning  will  focus 
particularly  on  the  importance  of  good  documentation  in  recording  risk  of  suicide  or  self-harm 
following a consultation when someone has been assessed as having suicidal ideation or is at risk 
of acts of self-harm.  

The  practices  across  the  ICS  will  also  be  reminded  of  the  importance  of  a  good  mental  health 
assessment using recognised mental health tools. There are already templates for PHQ9 and GAD 
on the GP systems for them to use.  The learning will be shared with practices in July 2022 in the 
GP bulletin. In September 2022, there will be a virtual training session, which will be recorded, on 
mental health assessment, which will also include documentation. The recording will be sent to all 
practices following the event.  

Practices  will  also  be  reminded  of  the  importance  of  completing  Serious  Event  Audits  for 
serious/unexpected  incidents.  The  NHS  Frimley  ICB  quality  team  will  be  requesting  the  Serious 
Event Audits from practices as part of the investigation into suicides recorded as part of the NHSE 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 serious incident framework to review that learning points have been considered.  Learning will be 
shared in a number of ways with practices, through education at the previously mentioned mental 
health training session; by working with the mental health clinical leads; the GP bulletin in July 2022 
and at the regular GP meetings and as part of the prescribing updates. It is anticipated that these 
actions will be completed by September 2022.   

Closer monitoring 

The Regulation 28 Report will also be shared with the ICS Mortality Review Group and ICS Quality 
Surveillance Group for assurance on delivery in August 2022. The actions will then be monitored 
quarterly from   the ICB, Practice and Talk Plus.  The NHS Frimley ICB quality team will also be 
reviewing the action plan with the provider and the Practice. The Practice will be put on the NHS 
Frimley  ICB  concerns  framework  for  close  monitoring  on  patient  safety  while  their  actions  are  in 
progress and then this will be reviewed by the  NHS Frimley ICB quality and primary care teams. 
TalkPlus will be monitored against compliance through the contractual route. The NHS Frimley ICB 
has already met with both providers to work with them on their action plans, these meetings occurred 
in June 2022.  

Improved medication management 

Across  Frimley  there  is  an  evidence-based  formulary  the  production  of  which  is  supported  by  a 
multidisciplinary team and this details prescribing practices that are routinely used in the area. After 
reviewing  this  case,  we  have  considered  that  although  there  are  also  a  number  of  national 
publications  that  highlight  the  increased  risk  of  suicidal  behaviour  for  a  patient  initiated  on 
antidepressants (for example, the BNF, MHRA and NICE) the risks should be further highlighted on 
the  local formulary.  Action  will  be  taken  to  ensure  that  the  local formulary highlights  the national 
guidance  more  acutely,  in  addition  to  the  currently  available  information.  Furthermore,  the 
development  of  a  point  of  prescribing  alert  will  be  undertaken  to  ensure  that  prescribers  are 
reminded about the national guidance relating to potential increased risk in young people. 

The  prescribing  choices  undertaken  by  the  GP  were  in  line  with  guidance:  prioritising  non-
pharmacological  support  for  people  with  insomnia,  providing  a  short  course  of  zopiclone  when 
essential;  and  prescribing  mirtazapine  for  depression  where  there  is  also  significant  insomnia. 
However,  we  are  undertaking  additional  steps  to  provide  clearer  advice  at  initiation  of  a  new 
antidepressant.  This  will  state  that  highlighting  the  potential  for  worsening  depressive  symptoms 
and increasing suicidal ideas is a key step that should be undertaken in every relevant case. This 
will happen on 12th July 2022 following approval from the medicine optimisation committee. Local 
prescribers will be reminded of this via our communication channels.  This is happening through 
July and August 2022. 

We hope that this letter provides you with the assurance about the ways the  NHS Frimley ICB is 
responding to the concerns raised. Please do let us know if we can assist in addressing any further 
concerns you may have. 

Yours sincerely 

Chief Nurse 

NHS Frimley ICB.