Recipient

Chelsfield Surgery

First report 21 Jun 2024•Latest report 21 Jun 2024

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 1
Stated actions: 11

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

11stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Chelsfield Surgery linked to the concerns in each report. Select any concern, action or position to view the source wording.

21 Jun2024
East Sussex
Concerns raised1
1. Failure to review medication continuity when deregistering patients
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Update the Repeat Prescribing Policy to require adequate medication supply for removed patients until they register elsewhere.
  Stated completed
2. Action
  Provide removed patients with a final-prescription letter explaining the need to register elsewhere for medication continuity.
  Stated planned
3. 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.
  Stated in progress
1. Action
  Audit deductions from the previous three years to identify affected patients and additional learning points.
  Stated in progress
2. Action
  Circulate updated policies and SEA learning points to all non-clinical staff by email.
  Stated completed
3. Action
  Hold a Significant Event Analysis meeting to examine the deduction and agree learning points.
  Stated completed
4. Action
  Conduct monthly audits of future deductions and feed findings into weekly safeguarding meetings.
  Stated planned
5. Action
  Hold a practice meeting for non-clinical staff to disseminate SEA conclusions and explain updated deduction procedures.
  Stated planned
6. Action
  Review deductions involving safeguarding concerns in weekly safeguarding meetings and check that clinical needs and medication access are met.
  Stated planned
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.

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. 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. ”
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
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
Page 1 · response
Published 29 July 2024
Open published response
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
Page 2 · response
Published 29 July 2024
Open published response
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
Page 2 · response
Published 29 July 2024
Open published response
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
Page 2 · response
Published 29 July 2024
Open published response
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
Page 2 · response
Published 29 July 2024
Open published response
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
Page 1 · response
Published 29 July 2024
Open published response
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
Page 2 · response
Published 29 July 2024
Open published response
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
Page 2 · response
Published 29 July 2024
Open published response
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
Page 2 · response
Published 29 July 2024
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised1

Failure to review medication continuity when deregistering patients

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

Actions described in response 9