18 May 2022 Matthew John Evans · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 12 Failure to ensure review of correspondence from TalkPlus View source Lack of guidance on thresholds for referral to secondary mental health services View source Failure to undertake mental health assessment and identify need for further or secondary mental health support View source Failure to document warnings about Mirtazepine side-effects and increased suicidal ideation risk View source Failure to confirm electronic letters are read and acted upon View source Prescribing of Mirtazepine without sufficient mental health prescribing competence View source Lack of ongoing mental health training for GPs View source Failure to offer face-to-face consultation or arrange follow-up View source Failure to ask about or document suicidal ideation and self-harm View source Failure to investigate and review deaths for learning and implementation of necessary changes View source Lack of prescribing policy for Mirtazapine, antidepressants and anxiolytics View source Failure to seek permission to involve partners and family in ongoing care View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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. 13
Action
Send PHQ9 and GAD7 questionnaires before consultations and record their scores directly in EMIS Web.
Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source
Action
Discuss unexpected deaths at weekly practice clinical meetings attended by GP clinicians and Partners.
Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source
Action
Offer face-to-face appointments to patients presenting with new mental-health issues.
Stated completedThe respondent said that this action was complete when they made their response on 19 May 2022. View source
Action
Review patient follow-up timescales and require GPs to book follow-up appointments rather than asking patients to call.
Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source
Action
Audit patient use of the specified medication, present the results, and identify any required patient-safety actions.
Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source
Action
Conduct a computer-system audit of TalkPlus letters to verify receipt and reading, and share the results, analysis and recommended actions with Clinical Governance.
Stated completedThe respondent said that this action was complete when they made their response on 19 May 2022. View source
Action
Conduct a significant event analysis of the death with clinical staff and review the resulting learning and actions.
Stated completedThe respondent said that this action was complete when they made their response on 19 May 2022. View source
Action
Circulate NICE prescribing, treatment and patient-information guidance, CCG guidance, and Frimley ICS medicines-optimisation guidance to all clinicians.
Stated completedThe respondent said that this action was complete when they made their response on 19 May 2022. View source
Action
Attend a CPD course on recognising mental-health suicide risks for reminder and ongoing professional development.
Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source
Action
Create and circulate an Accurix template directing clinicians to GAD and PHQ9 resources for detecting anxiety and symptoms.
Stated completedThe respondent said that this action was complete when they made their response on 19 May 2022. View source
Action
Provide in-house mental-health training through an identified clinical psychologist for practice clinicians.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 May 2022. View source
Action
Seek permission, in appropriate situations, to contact and inform patients’ family members.
Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source
Action
Share the significant event analysis findings with practice staff, the CCG and CQC.
Stated completedThe respondent said that this action was complete when they made their response on 19 May 2022. View source See 10 more actions
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AI-generated summary
Matthew John Evans · 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
Matthew John Evans was a 47-year-old man who developed insomnia, anxiety and depression during the third COVID-19 lockdown and died on 16 June 2021 after ending his life. The principal concerns related to the GP’s lack of mental-health assessment, suicide-risk assessment, follow-up and consideration of referral; the general practice’s prescribing, communication and clinical-governance arrangements; and TalkPlus’s lack of clear guidance on referral to secondary mental-health services.
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 Farnham Park Health Group; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure review of correspondence from TalkPlus
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” 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 Farnham Park Health Group; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on thresholds for referral to secondary mental health services
Wider context from the report “3. The actions of TalkPlus
There does not appear to be robust guidance or a policy as to the threshold necessary to refer a patient to secondary mental health services in Matthew’s circumstances where his mental health had deteriorated as the sessions progressed and he had began to indicate suicidal ideation and self-harm on a background of no previous mental health difficulties.
” 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 Farnham Park Health Group; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake mental health assessment and identify need for further or secondary mental health support
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” 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 Farnham Park Health Group; that does not assign responsibility.
PFD Monitor interpretation Failure to document warnings about Mirtazepine side-effects and increased suicidal ideation risk
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” 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 Farnham Park Health Group; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm electronic letters are read and acted upon
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” 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 Farnham Park Health Group; that does not assign responsibility.
PFD Monitor interpretation Prescribing of Mirtazepine without sufficient mental health prescribing competence
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” 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 Farnham Park Health Group; that does not assign responsibility.
PFD Monitor interpretation Lack of ongoing mental health training for GPs
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” 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 Farnham Park Health Group; that does not assign responsibility.
PFD Monitor interpretation Failure to offer face-to-face consultation or arrange follow-up
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” 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 Farnham Park Health Group; that does not assign responsibility.
PFD Monitor interpretation Failure to ask about or document suicidal ideation and self-harm
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” 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 Farnham Park Health Group; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate and review deaths for learning and implementation of necessary changes
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” 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 Farnham Park Health Group; that does not assign responsibility.
PFD Monitor interpretation Lack of prescribing policy for Mirtazapine, antidepressants and anxiolytics
Wider context from the report “2. The actions of the General Practice
No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice. There is no confirmation electronic letters have been signed as read and acted upon by the relevant GP. No evidence was provided with regard to ongoing training in mental health for GP’s. Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.
” 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 Farnham Park Health Group; that does not assign responsibility.
PFD Monitor interpretation Failure to seek permission to involve partners and family in ongoing care
Wider context from the report “1. The actions of the General Practitioner
The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew. The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm. The GP did not offer a face-to-face consultation or arrange a follow up appointment. The GP declined to prescribe Zopiclone and whilst he referred Matthew to the benefits of Melatonin he did not offer a prescription. He prescribed Mirtazepine having not done so before for someone in Matthew’s position on a background of having no post graduate qualifications in mental health. Furthermore, he did not document any warning of the possible side-effects of this drug including the possible increased risk of suicidal ideation with commencing the drug. It is unclear whether the GP had read the letters from TalkPlus. He did not ask permission as to whether it was possible to inform or involve Matthew’s partner and family in his on-going care.
” 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 Send PHQ9 and GAD7 questionnaires before consultations and record their scores directly in EMIS Web.
Verbatim wording from the response “18. PHQ9/GAD7 questionnaire will now be sent to patients to complete ahead of their consultations. Scores will be written directly into EMIS Web so available during the consultation with the patient.” Source location Response from Farnham Practice
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 Discuss unexpected deaths at weekly practice clinical meetings attended by GP clinicians and Partners.
Verbatim wording from the response “45. Going forward, as part of the Practice’s Clinical Governance Policy, it was further agreed that unexpected deaths will be discussed at the Practice Clinical Meetings’ Meetings which are held every week and attended by the GP clinicians and Partners.” Source location Response from Farnham Practice
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 Offer face-to-face appointments to patients presenting with new mental-health issues.
Verbatim wording from the response “24. ████████ and the Practice have agreed that patients presenting with new mental health issues, are to be offered face-to-face appointments. This policy was introduced with immediate effect from the date of the SEA.” Source location Response from Farnham Practice
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 patient follow-up timescales and require GPs to book follow-up appointments rather than asking patients to call.
Verbatim wording from the response “25. The Practice will review patient follow up timescale and GP should book them in rather than ask patient to call in as they may not be able to get through.” Source location Response from Farnham 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 Audit patient use of the specified medication, present the results, and identify any required patient-safety actions.
Verbatim wording from the response “38. The Practice will conduct an Audit of patient ████████ use by August 2022. To present audit results and identify if there is/are action/s required in relation to patient safety i.e. patient education regarding the use of the drug, follow-up to check patient remained safe in taking this drug, and does or has the patient required secondary referral to be supported by the community mental health team.” Source location Response from Farnham Practice
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 a computer-system audit of TalkPlus letters to verify receipt and reading, and share the results, analysis and recommended actions with Clinical Governance.
Verbatim wording from the response “32. An Audit of the GP computer system was completed on 31 May 2022. This confirms ████████ read two of the letters from TalkPlus within 24 hours of receipt, one was received and read within 3 working days. There is a History Trail in Docman which automatically records receipt/read for every document received [see Action Plan attached].” Source location Response from Farnham Practice
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 a significant event analysis of the death with clinical staff and review the resulting learning and actions.
Verbatim wording from the response “3. The Partners at the Practice were awaiting the outcome of the Inquest before undertaking a Serious Event Audit (“the SEA”). The Practice Partners considered it appropriate that the SEA took place when it was possible to maximize the number of clinicians attending the audit meeting. The Practice conducted a SEA on Tuesday 31 May 2022. There having been delays due to bereavement, sickness, leave and the various Bank Holidays which interrupted the Practice working timetable, which impacted on the availabilities of the various members of Practice team. Six clinicians participated in the SEA, including ████████.” Source location Response from Farnham Practice
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 NICE prescribing, treatment and patient-information guidance, CCG guidance, and Frimley ICS medicines-optimisation guidance to all clinicians.
Verbatim wording from the response “36. The Practice repeats and relies upon the response at paragraph 30 above.” Source location Response from Farnham Practice
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 Attend a CPD course on recognising mental-health suicide risks for reminder and ongoing professional development.
Verbatim wording from the response “13. ████████ has identified a CPD course concerning Mental Health – recognize suicide risks, which he shall be attending by way of reminder and on-going professional development.” Source location Response from Farnham Practice
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 circulate an Accurix template directing clinicians to GAD and PHQ9 resources for detecting anxiety and symptoms.
Verbatim wording from the response “20. Accurix Template created and circulated to all clinicians on where to find GAD & PHQ-9 to detect patient’s anxiety and symptoms.” Source location Response from Farnham Practice
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 in-house mental-health training through an identified clinical psychologist for practice clinicians.
Verbatim wording from the response “41. The Practice is liaising with mental health providers to arrange in-house training. The Practice contacted Spires Clare Park, a local hospital which provides private health care on 31 May 2022 to organise Mental Health training. Spire Clare Park have a programme where consultants of various specialties provide educational teaching/meetings for local GPs,. No consultant psychiatrist was available to offer training. The Practice communicated with the mental health lead at the CCG on 21 June 2022 regarding mental health pathways and the Primary Care Network Additional Roles Reimbursement Scheme roles and Cardinal Clinic (a private medical hospital which also provides educational programmes for GPs but they were not able to offer training.” Source location Response from Farnham Practice
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 Seek permission, in appropriate situations, to contact and inform patients’ family members.
Verbatim wording from the response “35. Going forward in appropriate situations ████████ will seek permission to contact and inform family members.” Source location Response from Farnham Practice
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 Share the significant event analysis findings with practice staff, the CCG and CQC.
Verbatim wording from the response “44. The Practice has shared the findings of the SEA with all staff at the practice, the CCG and CQC.” Source location Response from Farnham Practice
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 The Practice disputes that the death was not investigated or reviewed, stating that it was discussed promptly and later subjected to significant event analysis.
Verbatim wording from the response “Matthew’s death was not investigated or reviewed by the GP practice with the consequence no learning points have been considered or, if necessary, changes implemented, giving rise to concern over the lack of robust clinical governance procedure within the practice.” Source location Response from Farnham Practice
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 Face-to-face consultation was not offered because pandemic advice was to avoid face-to-face appointments where possible.
Verbatim wording from the response “The GP did not offer a face-to-face consultation or arrange a follow up appointment.” Source location Response from Farnham Practice
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 The Practice concluded that the prescribed medication was appropriate because insomnia was the patient's original primary reason for contacting it.
Verbatim wording from the response “28. ████████ has prescribed ████████ before. He was asked by H.M. Coroner whether he had ever prescribed ████████ to a middle-aged man experiencing mental health issues for the first time before. ████████ confirmed this was the first time he had initiated the prescription of this medication to someone not in a care home (i.e., not elderly).” Source location Response from Farnham Practice
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 The GP disputes that no mental health risk assessment occurred, stating that he asked about suicidal ideation and self-harm.
Verbatim wording from the response “The GP did not undertake a mental health assessment to assess the severity of Matthew’s difficulties and to ascertain whether further support or referral to secondary mental health care were indicated in any of the four telephone consultations. He did not ask or document at any time if Matthew had any suicidal ideation or acts of self-harm.” Source location Response from Farnham Practice
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 The Practice relied on NICE recommendations, BNF information and NICE CKS guidance despite there being no specific CCG prescribing guideline.
Verbatim wording from the response “No policy was provided to assist GP’s with prescribing of ████████ antidepressants and anxiolytics in general practice.” Source location Response from Farnham Practice
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 The response disputes that secondary mental health referral was indicated, stating that the patient did not meet referral criteria and remained low risk.
Verbatim wording from the response “10. The Deceased did not come close to a referral to the urgent assessment unit.” Source location Response from Farnham Practice
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 The audit disputed uncertainty about whether TalkPlus letters were read, confirming that all three were read within recorded timeframes.
Verbatim wording from the response ““It is unclear whether the GP had read the letters from TalkPlus.”” Source location Response from Farnham Practice
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations