Zarah Ravn

THE ASHLEA MEDICAL PRACTICE

Gilbert House

Linden House

LINDEN HOUSE SURGERY 30 Upper Fairfield Road Leatherhead Surrey KT22 7HH Tel No: | |
GILBERT HOUSE SURGERY 39 Woodfield Lane Ashtead Surrey KT21 2BQ Tel No:

Mrs Krestina Hayes
HM Assistant Coroner for Surrey
10 July 2024

Dear Ma’am

Re Inquest touching upon the death of Zarah Ravn
Regulation 28 Report Response

We are writing to provide our response to your Regulation 28 Report dated 8 May 2024.

We have read the report carefully and set out below the action that has been taken, in particular the changes to our
Severe Mental Illness (SMI) annual review processes and improvements to our Hormone Replacement Therapy (HRT)
prescribing and review practices.

Action Taken before the Inquest

Ms Ravn’s death was discussed as a significant event at a Practice Meeting on 28 November 2023. Ms Ravn had had
regular physical and mental health reviews up to December 2019, which was the last time a physical, mental health and
medication review are all recorded. From 2020 onwards, the reviews became more sporadic — most likely due to the
impact of the Covid-19 pandemic (chronic disease / long-term condition reviews were suspended for GP Practices in 2020
in order to free-up time to manage the pandemic). Ms Ravn had a physical health review in February 2021 and January
2023 and her mental health was discussed at appointments in March 2021 and February 2022, but there were no formal
mental health care plan / medication reviews after December 2019. A number of actions/learning points were identified
at the significant event discussion in November 2023, including:

e A need for a new/consistent process for tasking GPs to undertake mental health and medications reviews once
physical health checks and blood tests have been completed for patients with an SMI.

e Reminders to clinicians to use templates for assessing patient with an SMI, which will prompt a holistic review and
ensure diary review dates are created.

e A need to remind clinicians to document risk assessments regarding the seriousness of suicidal intent and
arrangements for follow-up.

e Training for Healthcare Assistants on the annual physical health check for patients with an SMI.
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We noted during the discussion that since 2022, an IT Assistant had been employed to assist with long-term condition
management reviews (and identifying when these were outstanding) and that this was assisting with identifying
outstanding chronic disease reviews.

We also noted that questions around changes to mood had been included in our updated HRT review protocols, meaning
that mood assessment was now routinely included as part of the HRT prescribing review.

The actions identified above were disseminated to staff and actioned in the months that followed. However, during the
course of the Inquest on 20 February 2024, it became clear that these steps were insufficient to ensure that all aspects of
the SMI annual review were being done concurrently and consistently. During the Inquest, it also became clear that
there was no process in place for checking that improvements to HRT reviews were taking place.

Action Taken after the Inquest

Ms Ravn’s case and the findings at the Inquest were reviewed again after the Inquest. We noted that whilst the
improvement actions implemented following Ms Ravn’s death were individually helpful, a more joined-up approach was
needed to create a smooth and robust process for (all aspects of) the annual SMI reviews, and to ensure that changes to
both SMI review and HRT prescribing practices and recommendations had been embedded. These further development
actions were added to the agenda for a Practice Meeting on 13 March 2024, with the intention to then create new
policies to (1) codify the updated annual SMI review and HRT prescribing review processes; (2) set clear expectations
against which compliance can be audited; and (3) improve patient care delivery and experience in these areas.

New Severe Mental Illness Annual Reviews Policy

We enclose a copy of the Practice’s new Severe Mental Iliness Annual Reviews Policy. This policy creates a process for
making sure that patients with an SMI have annual physical, mental health and medication reviews. The policy should be
self-explanatory, but we have summarised below, with some additional comments about the rationale behind the
changes made:

1. Our IT Assistant runs searches of the SMI Register once a month to check for any patients who have not had a
physical health review in the past 12 months.

2. A list of any relevant patients is then passed to the Healthcare Assistant who contacts the patient(s) to make
appointments for the annual physical health review.

3. During the physical health review appointment, the HCA books the patient’s Mental Health and Medication
Review appointment with a GP, to take place within 2 weeks. This is a new step to ensure that all aspects of the
annual SMI review are completed, and as simultaneously as possible (as opposed to the HCA (physical health
check) and GP (mental health and medication reviews) being done at different times of the year, which had been
happening before). The two-week gap between the physical health check and the mental health/medication
reviews with the GP is however intentional, so that the GP can review/act on the blood results as necessary at the
medication review. This would not be possible if the physical, mental health and physical health appointments
were all booked for the same day, as the blood results would not be available.

4. Once the GP has completed the mental health and medication review, they record this with a coded entry in the
notes (“Mental health annual review completed”) and set a date for the next review within 12 months. The
coded entry / review date will show up in IT Assistant’s searches the following year, to start the annual review
process again. The diary review date also appears as an alert in the patient’s record if/when it becomes overdue,

as an additional safeguard.

5. Staff are expected use Ardens templates for documenting physical, mental health and medication reviews. This is
new — particularly for GPs, who did not always use templates once these became available within the Practice.
Ardens is a clinical decision and workflow support system that assists GP Practices with optimising patient care
and recording data. They produce clinical templates designed to standardise consultations for chronic disease
management, which are updated regularly in line with the latest national guidelines. The use of Ardens templates

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for annual SMI reviews assists with structuring the review, ensuring that all the necessary checks and steps are
taken, documenting the review and capturing relevant coding data to assist with monitoring.

In relation to point 1 above, we are aware that the Coroner was concerned that this search process had failed in Ms
Ravn’s case because she did not have an annual review in 2022. However, it appears there was a delay rather than a
failure to organise the review for Ms Ravn once the IT assistance was in place in 2022: it had taken time for the IT
Assistant to undergo training and for staff to work through the backlog of patients requiring review (for all chronic
conditions) after Covid. This meant that whilst additional IT support was in place to identify patients in need of reviews in
2022, not all patients had their annual chronic disease reviews in 2022. Ms Ravn had a physical health check on 31
January 2023. There were no processes in place at that time to link the physical health check with other annual SMI
review requirements, but that has now been addressed through point 3 above.

Audit

The new Annual SMI review policy was approved on 30 March 2024 and has been disseminated to staff. Our IT Assistant
has been carrying out monthly reviews to check that the searches she is doing is resulting in annual checks being
completed. Feedback so far indicates that the system is working well: patients are attending for their physical and
mental health/medication reviews, and with a better attendance rate too because the patient is now getting the doctor’s
appointment booked by the HCA before they leave the physical health check appointment.

Compliance with the new SMI review policy will be formally audited in September 2024 to check that it is working and
that staff are complying with the requirements. It will be reaudited if necessary within 3-6 months and then added for
review on an ongoing basis at the Practice’s annual compliance meeting.

New HRT Prescribing Policy

We have also now introduced a written HRT Prescribing Policy (as an appendix to our existing Prescribing Policy) to
standardise our practices in this area and to ensure all women receiving HRT are reviewed regularly in line with current
guidance. We enclose a copy of the HRT Prescribing Policy. Again, this policy should be self-explanatory, but we have
highlighted some of the key changes below:

1. The policy confirms that there must be a review within 3 months following the first prescription of HRT.

2. The use of the relevant Ardens Template is advised to assist with ensuring a comprehensive review process in line
with the most up to date guidance.

3. Staff have been given training on setting up a standardised Accurx Questionnaire to trigger the first HRT review.
Accurx is another workflow toolkit used in Primacy Care, which enables Practices to communicate with patients
electronically, and it is utilised as below for HRT reviews:

(i) At the first appointment when HRT is prescribed, the GP prescribes no more than a 12-week supply of
HRT medication and enters a date in the patient’s notes for the HRT Accurx Questionnaire to be sent to
the patient via text message within 12 weeks. Patients are advised to expect a questionnaire, and that we
will use their responses to assess whether the HRT medication can be continued/any adjustments are
required and/or if they need to be seen again. The questionnaire contains all relevant questions to ask
when reviewing HRT, including changes in mood. We enclose a copy of the questions.

(ii) The patient has 7 days to respond to the questionnaire.

(iii) Once received, the questionnaire response is reviewed by the GP and they will decide future
management as appropriate, including programming further reviews as necessary until the patient is
settled on a stable dose. The policy confirms that once a patient is established on a stable dose, there
should be ongoing 12-monthly reviews as a minimum (to be completed by a GP or Pharmacist using the
relevant Ardens template).

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(iv) Generally speaking, we have found that patients are good at responding to the Accrux questionnaire and
providing articulate/detailed answers. However, if for any reason a patient does not respond within 7
days, the doctor receives a notification so the patient can be contacted again. The policy is clear that a
second prescription for HRT should not be issued unless the patient has responded to the questionnaire
or has had a review.

Audit

Compliance with the new HRT prescribing policy will be audited in September 2024 with a review of all patients started
on HRT medication since 1 April 2024, to check and ensure that (1) questionnaires are being sent; (2) appropriate and
timely reviews have taken place; and (3) templates and codes are being used for the HRT medication review process. The
need for further audit will be assessed again at that stage, and the policy will be included in our annual compliance
meeting.

Risk Assessment and follow-up for patients reporting thoughts of suicide

When Ms Ravn’s case was re-discussed at the Practice Meeting on 19 March 2024, we also took the opportunity to
remind GPs that a risk assessment must be completed when any patient expresses thoughts of suicide, and to reiterate
the importance of documenting the discussion and agreed action/follow-up arrangements. We went through what
questions to explore with the patient, what risk factors and protective features to consider and the options for
referral/follow-up. GPs have again been encouraged to use the Ardens template for suicide risk assessment, which helps
to ensure all relevant risk assessment factors are explored with the patient. We have also asked GPs to complete the
suicide prevention training on TeamNet by 30 September 2024, by way of refresher training, and this will be monitored
by our Practice Manager to ensure training has been completed.

Conclusion
We hope this letter demonstrates that the Practice has taken comprehensive action in response to the concerns
identified during the course of the Inquest, and that compliance with the improvement actions will be monitored over

the next six months (and beyond) to ensure changes to working practices are embedded and maintained.

Yours faithfull

For and on behalf of all Partners at Ashlea Medical Practice

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