Recurring concern

Failure to provide required annual primary-care health reviews

First to latest report 2 Apr 2024 — 8 May 2024

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
5

What this concern includes

Includes failures to require, arrange, complete or maintain annual primary-care reviews for patients with chronic, severe or otherwise safety-relevant health conditions, including physical-health reviews for people with severe mental illness and annual epilepsy reviews.

What is not included
  • Excludes specialist or hospital reviews that are not annual primary-care health reviews.
  • Excludes medication reviews, mental-health reviews or other condition-specific reviews when the annual primary-care health-review process is not the asserted unsafe condition.
  • Excludes generic appointment, staffing, documentation or guideline deficiencies unless they directly cause failure to provide a required annual primary-care health review.
  • Excludes one-off or urgent clinical reviews that are not part of an annual primary-care review requirement.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    Zarah RAVN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Zarah Ravn, aged 49, was found deceased at home on 3 September 2023 from mixed drug toxicity after consuming unprescribed oramorph and oxycodone alongside prescribed quetiapine. The substantive concerns included failures to carry out regular mental health, physical and medication reviews, inadequate monitoring of those reviews, and a lack of follow-up after HRT was prescribed following a reported deterioration in her mental health.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of yearly physical reviews

    Wider context from the report

    “Lack of compliance with NICE guidelines in carrying out yearly medication reviews, mental health reviews and physical reviews leading to lack of opportunity to take necessary interventions including medication adjustments and provision of necessary support. ”

    Source location

    Zarah RAVN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement and disseminate a Severe Mental Illness Annual Reviews Policy linking physical, mental-health and medication reviews, templates, coding and recall safeguards.

    Verbatim wording from the response

    “We enclose a copy of the Practice’s new Severe Mental Illness 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:”

    Source location

    Response from Ashlea Medical Practice
    Page 2 · response
    Published 14 May 2024

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Carry out monthly checks that SMI-register searches result in completed annual reviews.

    Verbatim wording from the response

    “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.”

    Source location

    Response from Ashlea Medical Practice
    Page 3 · response
    Published 14 May 2024

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Formally audit compliance with the SMI review policy in September 2024 and re-audit or review it thereafter as required.

    Verbatim wording from the response

    “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.”

    Source location

    Response from Ashlea Medical Practice
    Page 3 · response
    Published 14 May 2024

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The IT search process was delayed, not failed, because training and the post-Covid backlog prevented all annual reviews in 2022.

    Verbatim wording from the response

    “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.”

    Source location

    Response from Ashlea Medical Practice
    Page 3 · response
    Published 14 May 2024

    Open published response

  2. East London

    AI-generated summary

    Andrew Ewin-Ripp · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Andrew Ewin-Ripp, who had epilepsy, suffered a fit at home on 1 November 2022, was found in cardiac arrest, and died in hospital on 4 November 2022. The reported cause of death was sudden unexpected death in epilepsy (SUDEP). Concerns included lengthy waits for neurology care, the absence of clear guidance and systems for monitoring, discharge information, and urgent review after seizure recurrence.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of required annual epilepsy reviews in general practice

    Wider context from the report

    “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern: (1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures. (2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this. (3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge. (4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication. ”

    Source location

    Andrew Ewin-Ripp · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide members with SUDEP and seizure-safety education, including epilepsy-review and safety-checklist resources.

    Verbatim wording from the response

    “▪ SUDEP We currently have a resource available to members specifically on SUDEP and Seizure Safety (first produced in 2016 and updated in 2021). https://sudep.org/article/sudep-action-rcgp-launch-sudep-e-learning. It emphasises the role of General Practice in carrying out Epilepsy reviews using video and case studies in a 30min online resource. It highlights the use of the SUDEP and Seizure safety checklist https://sudep.org/checklist with resources for both professionals and patients. This course is free to access to all 54,000 RCGP members.”

    Source location

    Response from Royal College of General Practitioners
    Page 2 · response
    Published 4 April 2024

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide an epilepsy diagnosis and management learning module and podcast promoting regular annual review.

    Verbatim wording from the response

    “▪ Epilepsy Diagnosis and Management We also have a series of regular Essential Knowledge Updates. In our Update 17 (April 2016 updated April 2024) there is a specific module on Epilepsy Diagnosis and management. A podcast freely available to all in which ████████ talks about and promotes the e learning module highlighting the importance of regular annual review (EKU17: Epilepsy https://podcasts.apple.com/gb/podcast/eku17-epilepsy/id1474942018?i=1000453462614 )”

    Source location

    Response from Royal College of General Practitioners
    Page 2 · response
    Published 4 April 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    GP practices are required to follow clinical guidelines that include annual epilepsy reviews.

    Verbatim wording from the response

    “Your Report raised the concern that GP Practices are not required to carry out annual reviews of epilepsy patients. GP Practices required to follow and pay due regard to clinical guidelines. The National Institute for Health and Care Excellence (NICE) has issued clinical guidelines to general practice on annual reviews, including for Epilepsy.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 4 April 2024

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Commissioning general practice services is the responsibility of NHS England, not the respondent.

    Verbatim wording from the response

    “The College is not responsible for Commissioning Services from General Practice. In England this role falls to NHS England. General Practice has however been funded for Epilepsy management through the GMS contract and Quality and Outcomes Framework (QOF) since 2004. There is a requirement to maintain a register of adults receiving drug treatment for Epilepsy (EP001). Between 2004 and 2014 there were 2 additional indicators which fell out of the annual review process i.e. those who were seizure free (EP002) and the number of women receiving information and counselling about reproductive issues (EP003). The EP002 and EP003 indicators were retired in 2014 by NHS England. There has just been a Government Consultation which closed on the 7ᵗʰ March around the future of incentives in General Practice including QOF so there may be changes in coming years.”

    Source location

    Response from Royal College of General Practitioners
    Page 3 · response
    Published 4 April 2024

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026