Recipient

Stretton Medical Centre

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First report 14 Dec 2023•Latest report 14 Dec 2023

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
10

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
10stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Cheshire

    AI-generated summary

    Olivia Amy RUSSELL · 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

    Olivia Russell had a history of anxiety, started citalopram in November 2020, stopped taking it without consulting a GP around June 2021, and restarted it in August 2021 after a relapse. She took her own life on 19 September 2021. Concerns included a lack of recorded evidence that risks associated with stopping medication or initially feeling worse had been discussed, uncertainty about consistent adherence to relevant guidance, and delay in carrying out a significant event review after her death.

    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 Stretton Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in conducting significant event reviews after deaths

    Wider context from the report

    “I am also concerned that a significant event meeting (acknowledging I may have the name of this review meaning incorrect) has not yet taken place, despite Olivia’s death being over 2 years ago. The evidence of ████████ was that this will take place after the inquest and I am concerned that, if this is the practice following all deaths, there is a risk that learning from deaths will be delayed or missed. ”
    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 Stretton Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to routinely discuss medication relapse and worsening risks with patients

    Wider context from the report

    “During the inquiry, evidence was heard from ████████, one of your salaried GPs as to his interactions with Olivia, and based on the records, his colleagues’ interactions. There was no evidence within the notes that the risk of relapse if a medication is stopped was discussed in either November 2020 or August 2021, nor is there evidence that Olivia was told she may feel worse before she feels better. I did not find that this advice was not given, simply that I could not say either way. When asked, ████████ evidence was that you would discuss the risks when prescribing the drug, but was not entirely clear as to which risks he would discuss, and gave evidence that it is likely each GP has a different approach, bearing in mind the time limitations of the appointment. He could not say with confidence that every GP within the practice was discussing these key risks. A copy of the relevant NICE guidance was provided to me which states that these risks should be discussed with the patient, and I look specifically at sections 1.3.1 and 1.5.2 as a minimum. I am concerned that this guidance is not being followed as a matter of routine within the surgery and that this gives rise to a risk of future deaths. ”
    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

    Add a medication-label warning advising patients not to stop antidepressant or anti-anxiety medication without medical advice.

    Verbatim wording from the response

    “We have implemented a system whereby whenever an antidepressant or an anti-anxiety medication is prescribed a note will be added to patient and pharmacist to confirm “please do not stop these medications without medical advice”. This note will show up on the medication box label.”

    Source location

    Response from Stretton Branch Surgery
    Page 2 · response
    Published 28 December 2023

    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

    Remind GPs to discuss antidepressant risks and arrange follow-up, incorporating the requirement into new-starter and locum induction materials.

    Verbatim wording from the response

    “We have reminded all GPs that at the time of commencing an antidepressant, they should have a conversation with the patient mindful of the relevant clinical guidelines. The GP is then to book a follow up review with the patient. We have included this reminder in new starters and locum induction pack to ensure they act accordingly.”

    Source location

    Response from Stretton Branch Surgery
    Page 2 · response
    Published 28 December 2023

    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 a revised clinical meeting process to discuss all patient deaths monthly and complete Significant Event Analyses for unexpected deaths.

    Verbatim wording from the response

    “The Practice would like to reassure you that all patient deaths will be discussed at our monthly MDT meeting. We have revised our monthly Clinical Team Meeting template and every unexpected death will be discussed with a view to complete a Significant Event Analysis on them to share any learning.”

    Source location

    Response from Stretton Branch Surgery
    Page 2 · response
    Published 28 December 2023

    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 Olivia’s death to identify learning and required system or practice changes.

    Verbatim wording from the response

    “On 2 January 2024, the Practice conducted a clinical meeting / significant event meeting with our GP principal, ████████, our salaried GP, ████████, ████████ our regular Locum doctor, was unable to attend in person as she was working as locum doctor elsewhere at the time. We, as a practice, updated her on the discussion and the outcome.”

    Source location

    Response from Stretton Branch Surgery
    Page 1 · response
    Published 28 December 2023

    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 20-minute appointments for patients booking to discuss mental health concerns so medication risks can be discussed adequately.

    Verbatim wording from the response

    “To ensure risks are discussed with patients on anti-depressant medication, the Practice recognises that appointment times would need to be extended beyond the usual 10-minute slot. Hence patients booking to discuss a mental health concern will be given a 20-minute appointment. However, if a patient has not declared at the time of making the appointment that the appointment is to discuss a mental health concern, then the GP can send a message to reception to say that the consultation will take another 10 minutes and to keep any waiting patients informed of any delays. It is standard practice for our reception team to ask a patient the reason for their appointment at the time of booking an appointment to assist with planning the patient journey. There is no obligation on the patient to share information. While most patients declare their reasons for appointment some say it is “private”.”

    Source location

    Response from Stretton Branch Surgery
    Page 3 · response
    Published 28 December 2023

    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

    Recirculate NICE antidepressant guidance and GMC prescribing guidance to clinicians, highlighting discussion of medication risks.

    Verbatim wording from the response

    “2. To ensure relevant information is shared with a patient when commencing an antidepressant, in accordance with relevant clinical guidelines. This includes a discussion about risks, in particular the risk of relapse when stopping a medication and the risk of increased self-harm ideation at the outset of treatment.”

    Source location

    Response from Stretton Branch Surgery
    Page 2 · response
    Published 28 December 2023

    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

    Cascade Significant Event Analysis outcomes to clinical, reception and administration staff to support appropriate appointment booking and patient communication.

    Verbatim wording from the response

    “We have cascaded the outcomes of the Significant Event Analysis to all clinical members of our Practice team, which includes the reception and administration teams to ensure that they book the appropriate duration for each appointment and to reassure patients awaiting a consultation that they will be seen.”

    Source location

    Response from Stretton Branch Surgery
    Page 3 · response
    Published 28 December 2023

    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
60%40%
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