Tracy McCarthy

, FRCGP 
, MRCGP 
, FRCGP 
, MRCGP 
, MRCGP 
, MRCGP 

11 July 2024 

The Tredegar Practice 
35 St Stephens Road 
London E3 5JD 

Mr Ian Potter 
HM Assistant Coroner 
Inner North London 

Dear Mr Potter, 

re: Regulation 28: Prevention of Future Deaths report; Tracy Frances  
McCarthy (died 15 July 2023) 

Thank-you for your communication of 21 May 2024 relating to the death and inquest 
into the death of Tracy McCarthy. 

Your request for a response by us regarding action to be taken to prevent future deaths 
or risks is welcome and gives us an opportunity to review this sad case and identify 
ways of improving the safety and quality of our processes and patient care.  

I was the lead GP for care with Tracy until my retirement from clinical practice in 
September 2022. At that time, I had a limited number of patients with complex 
problems on my caseload and I took action to handover to my colleagues. Tracy was 
certainly one of these patients, perhaps the most complex. I was very sad to hear of 
Tracy’s death, but I was not aware of the findings of your inquest until your 
communication. 

As a result, I have looked through her notes and met with two of my GP colleagues (

 and 

) who have had the most (but not only) contact with Tracy 

following my retirement. We have reviewed the notes and agree that there are a 
number of gaps and failings in the notes management that led to the amitriptyline 
prescription being issued that was, in Tracy’s case, the wrong thing to do. I would say 
that I feel the most accountable in this case as the essential thing in this case was that 
the essential information be visible to all GPs managing Tracy’s care (and not just the 
person taking the lead).  

What was lacking to me as a retiring GP (and is still lacking) is a framework for creating 
a document for complex patients like Tracy so that any GP would be aware of the 
essentials of that patient’s history without having to search through the notes.  

It must be said that there is already in place a framework for certain patients (multi-
morbidity, usually elderly). These patients have an annual review from which emerges a 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Care Plan for the coming year (the patient is actively involved in the creation of this care 
plan). But this applies to a limited number of patients, and Tracy was not in this cohort. 

How to fill this gap? My initial thought was to create a ‘handover’ template to be 
completed when one GP retires or leaves the practice. As I was drafting this letter to you 
and the template, it became clear that something else was required. Not a document 
created when the lead GP retires or leaves the practice, but a document that is created, 
for this category of patients, in real time, in the present, to serve as a resource now, not 
waiting for a GP to retire.  

The proposed framework 

By framework I mean a process involving a number of elements: a clear purpose; 
training; documentation; planned review; quality assurance (is the process being 
carried out reliably, as intended?); quality control (are improvements to the process 
needed?). 

This framework has been created iteratively, and there will be further iterations (to 
improve it, to develop it). 

Purpose 

To provide a clear, readily accessible summary for complex patients to aid in safe and 
good quality planning and care for these patients. It is meant as an aid to assessment, a 
tool for review, and an aid to collaborative care by clinical staff. 

Rationale 

This framework has been designed in response to an avoidable patient death in a 
patient with complex health problems and behaviours. A major problem identified was 
lack of clear information to guide clinical staff who were not aware of the full picture. 
The information was in the notes, but not readily accessible, not readily visible. 

This framework was initially conceived as a ‘handover document’ to be used if a GP who 
led in the care of a complex patient retired or left the practice. It then became evident 
that this document was needed from the start, not when a GP left the practice.  

The Process 

1. All GPs, practice nurses, nurse practitioners, and other clinical staff working at the 
practice be aware of the framework and its rationale. Locum GPs will also need to be 
aware of the framework. This will require a systematic training. (It should be possible 
for this to be done efficiently, without adding significantly to the staffs’ considerable 
workload.) 

2. Identification of patients to be entered into the framework.  

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 What sort of cases should be considered? Complex patients with increased risks; 
patients who have a lead GP; patients in whom sharing information is important; 
patients in whom having a ‘global’ understanding is important. 

3. Each appropriate patient is added to the Risk Management & Care Planning 
Register (see separate document):  

a.  the lead GP will fill in the Risk Management & Care Plan (see separate 

document); the completed Care Plan will be filed in the patient’s Documents 
page.  

b.  In the EMIS patient record: in the Active Problem List add the SNOWMED 
Code Risk management administration (as Active; Significant, Permanent); 
in the free text space give name of lead GP, and the date of the Risk 
Management & Care Plan document. The purpose of this entry in the 
Problem List is to flag for any consulting GP (or other clinical member of 
staff) that this patient has complex needs and possible risks and signposts the 
Risk Management & Care Plan (which is designed to highlight and 
summarise the issues that a consulting clinician needs to keep in mind. This 
would also be of help to a GP doing repeat prescriptions). Of course, other 
clinicians, such as a pharmacist, would have access to this resource. 

c.  One thought would be that a copy of the most up-to-date Care Plan could be 
kept by the patient in case they are admitted to hospital. It might be helpful 
to include the Care Plan when referring the patient to hospital or community 
services. 

d.  The Risk management administration code will be added to the EMIS Alert 
flag list. (This alert is a pop-up in the bottom right of the patient’s record). 

3

 
 
 
 
 
 
 
 
 
 4.  Reviews: regular reviews will be needed in the process. 

Proposed reviews (subject to change in light of experience): 

a.  Overview of the Register quarterly. This is to give a sense of the scale and which 
patients are on the Register. This may trigger GPs (or other staff) to suggest a 
patient to be added.  

b.  Each GP lead will review their patients on the list 6 monthly (more frequently if 
need arises; an hospital admission should trigger a review). This will entail a 
review of the Risk Management & Care Plan and documenting the review in 
the Care Plan1. The updated copy to be filed on the date of review, and that (new) 
document will be signposted in the Problem List (that is, it is the most recent 
version that is signposted).  
One important consideration: in some cases, it may be useful/necessary to 
review the patient’s conditions and management with a colleague, or as a group 
of GPs (as in the GP Shared meeting). Having a ‘fresh set of eyes’ can often help. 

c.  A review of the overall framework/process to take place 6 monthly. The two 

questions to be asked: What is working well? What could be improved? 
Feedback will be given by the GP leads but also potentially by other clinicians 
who may have found the Risk Management & Care Planning framework 
helpful and may have suggestions for further development. 

d.  These reviews will need to be minuted, and these minutes circulated. 

5. To ensure that this framework remains active and effective, a GP lead for the 
framework/process will be appointed. The role of this GP will be to ensure that the 

1 This review and update will take into account possible changes in the patient’s circumstances, changes 
to the prescribed drugs, interventions, and so on. It will also be an opportunity to review the 
management. 

4

 
 
 
 
 
 
 
 
 
 reviews are taking place, making sure they are being scheduled, and making sure that 
the reviews are documented and that actions are actioned. This will not involve much 
work but will act as a reminder to ensure that this important work does not get 
forgotten, neglected. 

* 

This draft has been reviewed by 
the next GP Shared meeting (17 July 2024). Additional suggestions are likely to arise, 
and the next iteration of the framework will be created, and steps taken to implement 
the framework. 

. It will be presented at 

 and 

I would suggest that I provide you with an update and report of the implementation 
towards the end of September 2024. 

It has been suggested that we use this case in a presentation with GP colleagues, 
possibly on a PCN level, or among practices in Tower Hamlets. 

You may well have additional suggestions to make in light of this initial proposal. 

We are all saddened and chastened by this human tragedy. I hope we can learn 
important lessons from this review and the steps we will take so as to improve patient 
safety and quality of care going forward. 

Yours sincerely, 

GP Partner 

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