Recipient

Dearne Valley Group Practice

First report 6 Dec 2024•Latest report 6 Dec 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

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
8

Described in responses

Reports over time

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
8stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Dearne Valley Group Practice linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. South Yorkshire (Western)

    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

    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
    Page 1 · response
    Published 9 December 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

    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
    Page 1 · response
    Published 9 December 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 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
    Page 1 · response
    Published 9 December 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

    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
    Page 1 · response
    Published 9 December 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

    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
    Page 2 · response
    Published 9 December 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

    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
    Page 1 · response
    Published 9 December 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

    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
    Page 2 · response
    Published 9 December 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

    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
    Page 1 · response
    Published 9 December 2024

    Open published response
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
38%12%50%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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