Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0528, written 14 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Dec 2023 |
|---|---|
| Reference | 2023-0528 |
| Deceased | Olivia Russell |
| Coroner | Victoria Davies |
| Coroner area | Cheshire |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Stretton Medical Centre 1 CORONER I am Victoria DAVIES, Area Coroner for the coroner area of Cheshire 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 23 September 2021 I commenced an investigation into the death of Olivia Amy RUSSELL aged 25. The investigation concluded at the end of the inquest on 6 December 2023. The conclusion of the inquest was one of suicide. 4 CIRCUMSTANCES OF THE DEATH Olivia Russell had a history of anxiety which was initial managed without medication. In October 2020 she contacted your surgery and discussed options to treat her anxiety as this had worsened. She initially decided against anti-depressants but subsequently had another appointment on 2 November where she opted for a 10mg dose of citalopram. Following a period of apparent stability, Olivia stopped taking her medication in or around June 2021 without consulting a GP, subsequently suffering a relapse and re-starting her medication in August 2021. Sadly, Olivia took her own life on 19 September 2021. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) During the inquest, evidence was heard from his interactions with Olivia, and based on the records, his colleagues’ interactions. There was no evidence within the notes that the risk of relapse if a medication is stopped was discussed in either November 2020 or August 2021, nor is there evidence that Olivia was told she may feel worse before she feels better. I did not find that this advice was not given, simply that I could not say either way. , one of your salaried GPs as to When asked, evidence was that you would discuss the risks when prescribing the drug, but was not entirely clear as to which risks he would discuss, and gave evidence that it is likely each GP has a different approach, bearing in mind the time limitations of the appointment. He could not say with confidence that every GP within the practice was discussing these key risks. Regulation 28 – After Inquest Document Template Updated 30/07/2021 A copy of the relevant NICE guidance was provided to me which states that these risks should be discussed with the patient, and I look specifically at sections 1.3.1 and 1.5.2 as a minimum. I am concerned that this guidance is not being followed as a matter of routine within the surgery and that this gives rise to a risk of future deaths. I am also concerned that a significant event meeting (acknowledging I may have the name of this review meeting incorrect) has not yet taken place, despite Olivia’s death being over 2 years ago. The evidence of and I am concerned that, if this is the practice following all deaths, there is a risk that learning from deaths will be delayed or missed. was that this will take place after the inquest 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by January 31, 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Olivia Marks and Spencer I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 14/12/2023 Victoria DAVIES Area Coroner for Cheshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Stretton Medical Centre Stretton Branch Surgery
5 Hatton Lane
Stretton 43-45 Dudlow Green Road
Warrington Appleton
WA4 4NE Warrington
WA4 5EQ
Ms Victoria Davies
HM Coroner for Cheshire 29.01.2024
Dear Ms Davies
I write on behalf of the Stretton Medical Centre in response to your Regulation 28:
report to prevent future deaths, dated 14 December 2023.
We would like to thank you for bringing your concerns to the attention of the
Practice and we wish to reassure you that the care and support of our patients is of
the utmost importance to us. As a Practice, we were extremely saddened by
Olivia’s death, and we wish to once again offer our sincere condolences to Olivia’s
family.
On 2 January 2024, the Practice conducted a clinical meeting / significant event
meeting with our GP principal,
, our salaried GP,
, our regular
Locum doctor, was unable to attend in person as she was working as locum doctor
elsewhere at the time. We, as a practice, updated her on the discussion and the
outcome.
The purpose of the meeting was to discuss the outcome of the inquest and discuss
the information and concerns detailed in the Regulation 28 report.
We have considered the concerns and our response and action to each is below:
1. There was no Significant Event Meeting following Olivia’s death:
The original information received from the hospital as notification of Death had
limited information and detailed cause of death as cardiac arrest rather than
apparent suicide. Therefore, at the time of Olivia’s death, a Significant Event
Meeting was not carried out as the Practice awaited further information from the
hospital report.
Stretton Medical Centre Stretton Branch Surgery
5 Hatton Lane
Stretton 43-45 Dudlow Green Road
Warrington Appleton
WA4 4NE Warrington
WA4 5EQ
A SEA was conducted on 2 January 2024. The Practice accepts that an SEA should
have been performed sooner and prior to the inquest to ensure that learning from
the death was identified as soon as possible and changes made to systems or
practice where required. This was an oversight on our part, and the Practice would
like to apologise for the delay. This learning is shared with all the clinicians in our
practice and will be shared with clinicians in our primary care network for peer
review.
The Practice would like to reassure you that all patient deaths will be discussed at
our monthly MDT meeting. We have revised our monthly Clinical Team Meeting
template and every unexpected death will be discussed with a view to complete a
Significant Event Analysis on them to share any learning.
Where appropriate, the Significant Event Analysis of a death will be completed in
a month, ready to discuss in the next monthly Clinical Team Meeting.
2. To ensure relevant information is shared with a patient when
commencing an antidepressant, in accordance with relevant clinical
guidelines. This includes a discussion about risks, in particular the risk
of relapse when stopping a medication and the risk of increased self-
harm ideation at the outset of treatment.
As a result of the SEA on 2 January 2024, NICE Guidance (NG222 – Depression
in adults: treatment and management) has been recirculated to all clinicians
highlighting the need to appropriately discuss with patients any risks and in
particular, the risk of relapse. Also, we shared a copy of the General Medical
Council’s guidance on prescribing to doctors.
We have implemented a system whereby whenever an antidepressant or an anti-
anxiety medication is prescribed a note will be added to patient and pharmacist to
confirm “please do not stop these medications without medical advice”. This note
will show up on the medication box label.
We have reminded all GPs that at the time of commencing an antidepressant, they
should have a conversation with the patient mindful of the relevant clinical
guidelines. The GP is then to book a follow up review with the patient. We have
included this reminder in new starters and locum induction pack to ensure they act
accordingly.
Stretton Medical Centre Stretton Branch Surgery
5 Hatton Lane
Stretton 43-45 Dudlow Green Road
Warrington Appleton
WA4 4NE Warrington
WA4 5EQ
To ensure risks are discussed with patients on anti-depressant medication, the
Practice recognises that appointment times would need to be extended beyond the
usual 10-minute slot. Hence patients booking to discuss a mental health concern
will be given a 20-minute appointment. However, if a patient has not declared at
the time of making the appointment that the appointment is to discuss a mental
health concern, then the GP can send a message to reception to say that the
consultation will take another 10 minutes and to keep any waiting patients
informed of any delays. It is standard practice for our reception team to ask a
patient the reason for their appointment at the time of booking an appointment to
assist with planning the patient journey. There is no obligation on the patient to
share information. While most patients declare their reasons for appointment some
say it is “private”
The Practice have agreed to book a review with the patient two weeks later where
appropriate if medication has been commenced in relation to anxiety or depression
symptoms. This should be then followed up with a medication review after 4
weeks where appropriate.
Further appointments to be booked per advice from mental health practitioner,
Talking Matters, counselling services or at patient request.
The practice also has the option of signposting patients to the Practice Mental
Health Nurses, to follow these patients up, to again sign post them to appropriate
services like for CBT and counselling (to be another person who patient can speak
to), to review their risk and get back to GP if they need any safeguarding put in
place, to request GP to review them earlier than 2 weeks review as required, to
refer them to CRISIS team if their mental health deteriorated in interim period. In
addition, the Clinical pharmacist is available to assist with medication review to
again discuss side effects of medications, to again discuss the importance of taking
them regularly. The Clinical Pharmacist plays a vital role in prescribing weekly
medications or even daily medications in patients who are at risk of taking an
overdose.
We have cascaded the outcomes of the Significant Event Analysis to all clinical
members of our Practice team, which includes the reception and administration
teams to ensure that they book the appropriate duration for each appointment and
to reassure patients awaiting a consultation that they will be seen.
Stretton Medical Centre Stretton Branch Surgery
5 Hatton Lane
Stretton 43-45 Dudlow Green Road
Warrington Appleton
WA4 4NE Warrington
WA4 5EQ
We will arrange a follow-up appointment for any patients that DNA (did not
attend) their appointment, with an ACCURX text message or a call when unable to
send ACCURX text message.
If the Practice can be of any further assistance to the Coroner, please let us know.
Kind regards
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