21 Jun 2024 Thomas Joseph GERAGHTY · Prevention of Future Deaths report East Sussex
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Concerns raised 1 Failure to review medication continuity when deregistering patients View source
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. 9
Action
Update the Repeat Prescribing Policy to require adequate medication supply for removed patients until they register elsewhere.
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Action
Provide removed patients with a final-prescription letter explaining the need to register elsewhere for medication continuity.
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Action
Continue prescribing for removed patients with safeguarding concerns until registration elsewhere is confirmed, with any stopping decision made by a senior clinician and documented.
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Action
Audit deductions from the previous three years to identify affected patients and additional learning points.
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Action
Circulate updated policies and SEA learning points to all non-clinical staff by email.
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Action
Hold a Significant Event Analysis meeting to examine the deduction and agree learning points.
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Action
Conduct monthly audits of future deductions and feed findings into weekly safeguarding meetings.
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Action
Hold a practice meeting for non-clinical staff to disseminate SEA conclusions and explain updated deduction procedures.
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Action
Review deductions involving safeguarding concerns in weekly safeguarding meetings and check that clinical needs and medication access are met.
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AI-generated summary
Thomas Joseph GERAGHTY · 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
Thomas Joseph Geraghty entered the sea from a beach at Eastbourne on 28 June 2023 and was later recovered from the water; resuscitation was unsuccessful and his death was confirmed. The inquest concluded suicide. The report raises concern that patients may be deregistered from GP surgeries without adequate review or communication to ensure continued access to vital medication, particularly where no new GP details are provided.
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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 Chelsfield Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to review medication continuity when deregistering patients
Wider context from the report “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 deregistered 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.
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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 Update the Repeat Prescribing Policy to require adequate medication supply for removed patients until they register elsewhere.
Verbatim wording from the response “3. We have also reviewed and updated our Repeat Prescribing Policy. Our Policy now states:” Source location Response from Chelsfield Surgery
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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 removed patients with a final-prescription letter explaining the need to register elsewhere for medication continuity.
Verbatim wording from the response “(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.” Source location Response from Chelsfield Surgery
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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 Continue prescribing for removed patients with safeguarding concerns until registration elsewhere is confirmed, with any stopping decision made by a senior clinician and documented.
Verbatim wording from the response “(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.” Source location Response from Chelsfield Surgery
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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 deductions from the previous three years to identify affected patients and additional learning points.
Verbatim wording from the response “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.” Source location Response from Chelsfield Surgery
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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 Circulate updated policies and SEA learning points to all non-clinical staff by email.
Verbatim wording from the response “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.” Source location Response from Chelsfield Surgery
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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 Hold a Significant Event Analysis meeting to examine the deduction and agree learning points.
Verbatim wording from the response “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.” Source location Response from Chelsfield Surgery
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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 Conduct monthly audits of future deductions and feed findings into weekly safeguarding meetings.
Verbatim wording from the response “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. The results of this audit will be fed into the safeguarding meetings which take place weekly (see below).” Source location Response from Chelsfield Surgery
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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 Hold a practice meeting for non-clinical staff to disseminate SEA conclusions and explain updated deduction procedures.
Verbatim wording from the response “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.” Source location Response from Chelsfield Surgery
Open published response
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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 Review deductions involving safeguarding concerns in weekly safeguarding meetings and check that clinical needs and medication access are met.
Verbatim wording from the response “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.” Source location Response from Chelsfield Surgery
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations