Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0676, written 6 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Dec 2024 |
|---|---|
| Reference | 2024-0676 |
| Deceased | David Stables |
| Coroner | Marilyn Whittle |
| Coroner area | South Yorkshire (West) |
| Category | Suicide (from 2015) · Mental Health related deaths · Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
1 2 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Dearne Valley Group Practice CORONER I am Marilyn Whittle, Assistant Coroner, for the Coroner Area of South Yorkshire West 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 28 March 2024 I commenced an investigation into the death of David Stables. The investigation concluded at the end of the inquest on 4 December 2024. The conclusion of the inquest was 3 Suicide 1a Bilateral transection of the ulnar arteries 1b Incised wounds to the wrists CIRCUMSTANCES OF THE DEATH David Stables had a history of mental health issues and had taken two drug overdoses in 2020. He was prescribed sertraline in April 2020 and weaned himself off this in 2023. His last prescription was issued in July 2023. David attended many appointments at his GP practice from 2020 to 2023 regarding other issues unrelated to his mental health. In most of these encounters there is no record of any discussions regarding his mental health. Whilst he received repeat prescriptions for his sertraline, there is no recorded entry of a review of his mental health or appropriateness of the medication. It is noted that he had reduced this himself yet there is no recorded entry of a full review of his mental health at this time. 4 I am concerned that there were no recorded mental health or medication reviews from April 2020 until February 2024 when David attended the GP asking for help. I was unable to establish whether these reviews had taken place and just not been recorded or whether full mental health reviews had not taken place when they should have been. In February 2024 he attended the GP surgery and had a face to face appointment regarding his mental health. He had anxiety and had difficulties in sleeping and poor appetite. A shared decision was undertaken to put David on mirtazapine at 15mg and to follow up in 4 weeks time. I was informed that this was considered because of its side effects of sedation and increased appetite. A full mental state examination was undertaken which did not identify any Self harm or suicidal concerns. On 18 March 2024 he was seen again by the GP and there was some improvement. I was told that self harm and suicidal ideation were specifically discussed and they were strongly denied at both appointments. There was no concern from the GP when he called 2 days later to ask to increase his medication although it was accepted that had she known he had tried to contact the GP surgery on 5th 14 and 15th March then this may have changed her management in terms of obtaining more information either by reception or by another appointment. However, I do find that whilst he may have attempted to contact the GP it cannot be ascertained if these calls actually made it through to the reception team. I find that there is no evidence to say that this would have changed the management in terms of the medication although it may have been considered. Further there is evidence that even if medication had been increased it could have taken up to 4 - 6 weeks to show any benefit. David had been given all relevant safety netting advice for a crisis and this was provided verbally and by text message. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. - (1) I am concerned that there were no recorded mental health or medication reviews from April 2020 until February 2024 when David attended the GP asking for help. I was unable to establish whether these reviews had taken place and just not been recorded or whether full mental health reviews had not taken place when they should have been. (2) (3) ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Dearne Valley Practice have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 31 January 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, 5 6 7 setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Family - 8 I am also under a duty to send the Chief Coroner a copy of your response. 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. 6 December 2024 9 Signature Marilyn Whittle H.M Assistant Coroner for South Yorkshire West
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.
16/01/2025 Ms M Whittle HM Assistant Coroner Medico-Legal Centre Watery Street Sheffield S3 7ES Dear Ms Whittle Re: Ref: 2024-0676 - David Stables I am writing on behalf of the Dearne Valley Group Practice in response to the Regulation 28 Report dated 6 December 2024. We recognise the concerns you have raised about the lack of recording of mental health review and medication reviews. I have been assured that reviews had taken place, but they were not clearly or accurately recorded by the clinicians who consulted with Mr Stables. I am writing to set out the steps we have taken to assure that we will record this correctly going forward. 1. On December 18, 2024, we held a clinical meeting specifically to address the concern raised in the Regulation 28 Report. As a practice, we agreed a process which will assist current and future clinicians to correctly code into the clinical record when they have completed a mental health review and/ or a mental health medication review. To do this we have created a new mental health template to standardise the procedure which all clinicians now use. 2. We have reviewed each patient who is currently taking a selective serotonin reuptake inhibitors (SSRI) medication using the new template, starting with patients who have been discharged from a mental health service, as was Mr Stables. All patients have received a mental health review and a mental health medication review, who have been discharged from a mental health service. 3. We have updated the process for future patients following discharge from any mental health service. Now, when we receive notification that a patient has been discharged from any mental health service, we will contact the patient to book them an appointment for an initial mental health review. If the patient has been prescribed an SSRI, we will review the patient between 1 to 4 weeks (as determined by the reviewing clinician and with the patient’s agreement) and ongoing until they are stable. Once a patient is stable, they will be recalled for review every 6 months whilst they are being prescribed SSRI medication. 4. Patients starting an SSRI for the first time will also be seen every 1 to 4 weeks until they are stable, after which they will also be reviewed every 6 months whilst they are taking the medication. If patients choose to stop the medication themselves without our knowledge, this will be picked up at the review date and a mental health review and discussed with the patient. We are using scheduled tasks for The Thurnscoe Centre, Holly Bush Drive, Thurnscoe, Rotherham S63 0LT Tel: The Goldthorpe Centre, Goldthorpe Green, Goldthorpe, Rotherham S63 0EH Tel: Dearne Valley Group Practice & Partners www.dearnevalleygrouppractice.co.uk reminders to prompt clinicians to review the patients so that the responsibility is with the clinician and not the patient. 5. At our clinical meeting in December 2024 to discuss the recording of mental health reviews and mental health medication reviews, the clinical team were clear that reviews had happened in Mr Stables record, but the coding was missing. The coding requires a tick to be entered in a box which had not been completed. The new template which we created adds the code into the record when the clinician documents the history and examination of a patient when they are doing a metal health review, and there is a very clear prompt to confirm a mental health medication review has also taken place as well as set a scheduled task for the next review date. It has been made very clear to all the clinical team that in addition to undertaking reviews it is necessary that coding and clear wording of ‘mental health review’/ ‘medication review’ is included in order for clarity in the patient record so that it is clear to third parties that these have taken place, not just for mental health patients, but for all patients. 6. Patients who are still under the care of a secondary care mental health team will be reviewed by them, we will take over their care and treatment plan when the patient is discharged back to us. 7. Patients who we are currently prescribing medication for (all medication) will receive a medication review annually or biannually, and patients who are started on a new medication will also be monitored until stable at an interval in line with relevant guidance depending on their medication and then reviewed annually or biannually. We hope that this will reassure you that we have taken your concerns on board and taken steps to review our processes and implement change. Yours sincerely, Practice Manager Dearne Valley Group Practice The Thurnscoe Centre, Holly Bush Drive, Thurnscoe, Rotherham S63 0LT Tel: The Goldthorpe Centre, Goldthorpe Green, Goldthorpe, Rotherham S63 0EH Tel: Dearne Valley Group Practice & Partners www.dearnevalleygrouppractice.co.uk
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