Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0362, written 21 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jun 2024 |
|---|---|
| Reference | 2024-0362 |
| Deceased | Thomas Geraghty |
| Coroner | Laura Bradford |
| Coroner area | East Sussex |
| 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: 1 Chelsfield Surgery 1 CORONER I am Laura BRADFORD, Assistant Coroner for the coroner area of East Sussex 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 04 July 2023 I commenced an investigation into the death of Thomas Joseph GERAGHTY aged 39. The investigation concluded at the end of the inquest on 21 June 2024. The conclusion of the inquest was: Suicide 4 CIRCUMSTANCES OF THE DEATH On the morning of 28 June 2023 Thomas Joseph Geraghty entered the sea from the beach at Eastbourne. He was not witnessed entering the water. At around 11:45, Mr Geraghty’s body was seen floating by a nearby lifeguard and he was recovered to the beach. Resuscitation was attempted however it was sadly unsuccessful and death was confirmed. 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) Mr Geraghty had been prescribed anti-psychotic medication since 2007, which he took on a daily basis. His symptoms responded well to the medication and his mental health was assessed in 2015 as stable. Mr Geraghty informed his family that he felt safe taking his medication and had intended to remain on it for life. In January 2021, Mr Geraghty's GP surgery noted that he had moved out of its catchment area and a letter was sent to him advising him to register with a new surgery closer to his new home address. Mr Geraghty does not appear to have registered with a new surgery and remained a patient of his original surgery. He continued to receive a repeat prescription for his anti-psychotic medication and received his COVID vaccinations and also text messages from the surgery relating to smoking cessation advice up to November 2021. On 4 May 2022, the surgery sent Mr Geraghty a text message to confirm that they were still prescribing his medication and that he needed to provide his new surgery details. No details were provided by Mr Geraghty and he continued to be prescribed his anti-psychotic medication with the last prescription, a two-month supply, issued on 10 November 2022. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Mr Geraghty requested a repeat prescription via his usual automated service on 12 January 2023. Mr Geraghty appears to have been deregistered as a patient by the surgery on 16 January 2023 and there does not appear to have been any communication with Mr Geraghty at this time to inform him of the deregistration. Two chaser emails were sent to the surgery by the pharmacy to seek authorisation for the prescription but no response was received and Mr Geraghty, who had not yet registered with another surgery went without his anti-psychotic medication. He was not on any medication at the time of his death and family noted that some of his psychotic symptoms had returned in June 2023. I have a concern that individuals can be removed from the surgery as patients without any scrutiny as to whether the individual may be receiving vital medication (either for a mental health or physical health issue). There does not appear to be any process of review in relation to these patients to ensure that they will continue to receive their medication after they are deregistred from the surgery. This is of particular concern where a patient is deregistered and the surgery has not been provided with details of an individual's new GP. There is a concern that in these circumstances, an individual may be left without access to medication, which could cause or contribute to their death. 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 August 16, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Mr GERAGHTY’s family 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: 21/06/2024 Laura BRADFORD Regulation 28 – After Inquest Document Template Updated 30/07/2021 Assistant Coroner for East Sussex 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.
Chelsfield Surgery 13 August 2024 Dear HM Coroner I write on behalf of the Chelsfield Surgery in response to your Regulation 28 report dated 21 June 2024. We note the concerns you have raised and write to reassure you of the steps that the Surgery have taken to review how patients are deducted from the list and implement changes in our procedure when patients are removed in the future. Whilst writing, may we correct one matter noted on the Regulation 28 report. It is stated that Patient TG was deregistered as a patient by the surgery on 16 January 2023, which is inaccurate. The records indicate that the deduction request was submitted by the Practice on 28 November 2022 and completed on 29 December 2022. PCSE requested a copy of Patient TG’s medical records on 29 December 2022 and these were then sent on 16 January 2023. The member of the administrative team who dealt with transferring the records also made an entry into the medical consultations page to state that Patient TG had been deducted. This entry is dated 16 January 2023 – but the deduction had already taken effect from 29 December 2022. 1. On 25 July 2024 the practice held a Significant Event Analysis (“SEA”) meeting. The details of Patient TG’s deduction from the list were presented and learning outcomes discussed. These included: a clinician should have been consulted before the deduction was submitted in November 2022, safeguarding considerations ought to have been raised and discussed with safeguarding lead, Patient TG ought to have been sent a further letter informing him of the deduction and Patient TG ought to have received advice about continuing his medication supply. 2. As a practice we have considered, reviewed and updated our Removal of Patients Policy. Before any removal can take place it is now a mandatory requirement for the Safeguarding Lead to be consulted to ensure that all safeguarding concerns have been appropriately addressed. It is also now a mandatory requirement for a patient to receive a written notification when a deduction has taken place. 3. We have also reviewed and updated our Repeat Prescribing Policy. Our Policy now states: (a) In the event of removing a patient, we will ensure that the patient is provided with an adequate supply of medication to last until they register elsewhere, usually a maximum of 2 months’ supply. _________________________________________________________________________________________________ (b) We will now write to the patient to explain that this will be the final prescription from the practice and that the patient needs to register elsewhere to ensure continuity of their medication. In circumstances where there are safeguarding concerns, we will continue to prescribe medication until we receive confirmation that the patient has registered with a GP elsewhere. Any decision to then stop prescribing must usually be made by the safeguarding lead, or if they are unavailable then a senior clinician, and be clearly documented. (c) Any deduction that takes place will now be reviewed by the administration team in the immediate period after the deduction. This is a safety net process to ensure that any safeguarding concerns have been discussed and appropriate action taken. 4. The updated policies and learning points arising from the SEA have been circulated by email to all non-clinical staff. A practice meeting is scheduled on 14 August 2024 for all non-clinical staff to attend. The conclusions of the SEA will be disseminated to ensure that all staff learn from this case. We will highlight the updated policies and changes to procedure to ensure that there is no risk of repetition when deducting patients in the future. 5. The Practice Manager is conducting an audit of all deductions which have taken place in the last 3 years. Through this audit we hope to ensure that no other patients have been affected by a deduction and to check if there are any additional learning points which arise. 6. A continuing monthly audit will be undertaken by the Practice Manager for all patients deducted in the future. This audit will ensure that all deductions are appropriate, that any safeguarding concerns have been addressed and that the deduction does not disrupt continuity of care. This results of this audit will be fed into the safeguarding meetings which take place weekly (see below). 7. The Safeguarding Lead GP will now review any patient deductions where there are safeguarding concerns in the weekly safeguarding meeting. These patients will be discussed and checks made to ensure that clinical needs are being met, particularly with respect to prescriptions / access to vital medication. We hope that this will reassure HM Coroner that we have taken her concerns on board and taken steps to review our processes and implement change. Yours sincerely and on behalf of the Chelsfield Surgery _________________________________________________________________________________________________
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