8 May 2024 Zarah RAVN · Prevention of Future Deaths report Surrey
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Concerns raised 4 Lack of yearly mental health reviews View source Lack of yearly medication reviews View source Lack of HRT reviews following initial prescription View source Lack of yearly physical reviews View source See 1 more concern
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Implement and disseminate a Severe Mental Illness Annual Reviews Policy linking physical, mental-health and medication reviews, templates, coding and recall safeguards.
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Action
Carry out monthly checks that SMI-register searches result in completed annual reviews.
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Action
Introduce and disseminate a written HRT Prescribing Policy requiring timely and ongoing reviews supported by templates and standardised Accurx questionnaires.
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Action
Audit compliance with the HRT prescribing policy in September 2024, including questionnaire use, review timeliness, templates and coding.
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Action
Formally audit compliance with the SMI review policy in September 2024 and re-audit or review it thereafter as required.
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ashlea Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of yearly mental health 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ashlea Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of yearly medication 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ashlea Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of HRT reviews following initial prescription
Wider context from the report “Lack of compliance with HRT reviews following initial prescription in line with NICE guidelines.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ashlea Medical Practice; that does not assign responsibility.
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.
” Open source report
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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 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
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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
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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 Introduce and disseminate a written HRT Prescribing Policy requiring timely and ongoing reviews supported by templates and standardised Accurx questionnaires.
Verbatim wording from the response “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:” Source location Response from Ashlea Medical Practice
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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 Audit compliance with the HRT prescribing policy in September 2024, including questionnaire use, review timeliness, templates and coding.
Verbatim wording from the response “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.” Source location Response from Ashlea Medical Practice
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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
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations