Concerns raised 2 Failure to record mental health or medication reviews View source Failure to conduct full mental health reviews when required 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. 6
Action
Review all current SSRI patients, prioritising those discharged from mental health services, using the new template and completing mental health and medication reviews.
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Action
Contact patients discharged from mental health services, arrange initial reviews, and provide SSRI follow-up every one to four weeks until stable, then six-monthly reviews.
View source
Action
Review patients starting SSRIs every one to four weeks until stable, then every six months while they continue taking the medication.
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Action
Create and implement a mental health template that standardises coding of mental health and medication reviews in clinical records.
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Action
Inform the clinical team that reviews must include clear coding and wording in patient records for all patients.
View source
Action
Use scheduled reminders to prompt clinicians to complete patients’ mental health and medication reviews.
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AI-generated summary
David Stables · 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
David Stables had a history of mental health issues and attended his GP in February and March 2024 with anxiety, sleep difficulties and poor appetite. The inquest concluded that he died by suicide, with bilateral transection of the ulnar arteries and incised wounds to the wrists. The principal concern was that no mental health or medication reviews were recorded between April 2020 and February 2024, and it was unclear whether reviews had taken place but were not recorded or had not taken place when they should have.
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 Dearne Valley Group Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to record mental health or medication reviews
Wider context from the report “(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)
” 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 Dearne Valley Group Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct full mental health reviews when required
Wider context from the report “(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)
” 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 Review all current SSRI patients, prioritising those discharged from mental health services, using the new template and completing mental health and medication reviews.
Verbatim wording from the response “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.” Source location Response from Dearne Valley Group Practice
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 Contact patients discharged from mental health services, arrange initial reviews, and provide SSRI follow-up every one to four weeks until stable, then six-monthly reviews.
Verbatim wording from the response “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.” Source location Response from Dearne Valley Group Practice
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 patients starting SSRIs every one to four weeks until stable, then every six months while they continue taking the medication.
Verbatim wording from the response “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” Source location Response from Dearne Valley Group Practice
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 Create and implement a mental health template that standardises coding of mental health and medication reviews in clinical records.
Verbatim wording from the response “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.” Source location Response from Dearne Valley Group Practice
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 Inform the clinical team that reviews must include clear coding and wording in patient records for all patients.
Verbatim wording from the response “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.” Source location Response from Dearne Valley Group Practice
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 Use scheduled reminders to prompt clinicians to complete patients’ mental health and medication reviews.
Verbatim wording from the response “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” Source location Response from Dearne Valley Group Practice
Open published response
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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 Secondary mental health teams review patients remaining under their care; the practice assumes care after discharge.
Verbatim wording from the response “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.” Source location Response from Dearne Valley Group Practice
Open published response
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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 Mental health and medication reviews had occurred; the material problem was missing clinical-record coding.
Verbatim wording from the response “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.” Source location Response from Dearne Valley Group Practice
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations