14 Dec 2023 Olivia Amy RUSSELL · Prevention of Future Deaths report Cheshire
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Concerns raised 2 Delays in conducting significant event reviews after deaths View source Failure to routinely discuss medication relapse and worsening risks with patients 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. 7
Action
Add a medication-label warning advising patients not to stop antidepressant or anti-anxiety medication without medical advice.
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Action
Remind GPs to discuss antidepressant risks and arrange follow-up, incorporating the requirement into new-starter and locum induction materials.
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Action
Use a revised clinical meeting process to discuss all patient deaths monthly and complete Significant Event Analyses for unexpected deaths.
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Action
Conduct a Significant Event Analysis of Olivia’s death to identify learning and required system or practice changes.
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Action
Provide 20-minute appointments for patients booking to discuss mental health concerns so medication risks can be discussed adequately.
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Action
Recirculate NICE antidepressant guidance and GMC prescribing guidance to clinicians, highlighting discussion of medication risks.
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Action
Cascade Significant Event Analysis outcomes to clinical, reception and administration staff to support appropriate appointment booking and patient communication.
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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.
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× 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
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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 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
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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 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
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 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
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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 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
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 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
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 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
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 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations