PFD report

Tania Salekovna Hristova · Prevention of Future Deaths report

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Issued 28 Sep 2015•Wiltshire and Swindon

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to offer additional therapy for illness
  2. Lack of adequate review of antidepressant medication
    Part of recurring concern: Inadequate review of long-term medication use
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. Action

    Upgrade repeat prescribing to electronic prescribing and online ordering, enabling prescription messages and review requirements at the final issue.

    Stated by Partners at New Court SurgeryStated completedThe respondent said that this action was complete when they made their response on 28 September 2015.
  2. Action

    Record written medication-review summaries alongside medication-review codes to support reliable audits and identify patients needing review.

    Stated by Partners at New Court SurgeryStated plannedThe respondent said that this action was planned when they made their response on 28 September 2015.
  3. Action

    Audit patients taking SSRI antidepressants who were due medication reviews and arrange appointments by telephone or in person.

    Stated by Partners at New Court SurgeryStated completedThe respondent said that this action was complete when they made their response on 28 September 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing surgery systems are considered robust and sufficient to ensure medication reviews and counselling offers for patients taking SSRI antidepressants.

    Stated by Partners at New Court SurgeryExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to offer additional therapy for illness

Wider context from the report

“(2) This patient was not offered additional therapy such as counselling or CBT to help her deal with her illness. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of adequate review of antidepressant medication

Wider context from the report

“(1) This patient was prescribed antidepressant medication for 5 ½ years without adequate review. ”

Is this part of a recurring concern?

Yes — Inadequate review of long-term medication use.

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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

Upgrade repeat prescribing to electronic prescribing and online ordering, enabling prescription messages and review requirements at the final issue.

Verbatim wording from the response

“The practice has reviewed its repeat prescribing system and has now upgraded to electronic prescribing. This allows messages to be added electronically to prescriptions which the patient can read themselves or the pharmacist can then pass on, (if their prescription is sent to the pharmacist). The surgery has also moved over to an online ordering facility through our clinical computer system. Patients register securely to obtain password and log in details, which then allows them to request repeat medications that still have issues remaining. Once the medication has reached its last issue it would then require a medication review.”

Source location

2015-0392-Response
Page 2 · response
Published 28 September 2015

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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

Record written medication-review summaries alongside medication-review codes to support reliable audits and identify patients needing review.

Verbatim wording from the response

“At the significant event meeting, awareness was raised about the use of medication review codes. It was agreed that a written summary of the medication review was required to be recorded in the patient’s notes with the medication review “read code”. The use of medication review codes allows reliable audits to be performed and to identify patients that require a medication review.”

Source location

2015-0392-Response
Page 1 · response
Published 28 September 2015

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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 patients taking SSRI antidepressants who were due medication reviews and arrange appointments by telephone or in person.

Verbatim wording from the response

“An audit was undertaken to help identify patients on SSRI antidepressants that were due to have a medication review and arrangements were made to contact those patients to make a review appointment either by telephone or to take place in person at the surgery.”

Source location

2015-0392-Response
Page 2 · response
Published 28 September 2015

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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

Notify repeat-prescription patients about medication reviews, count down repeat issues, and contact persistent non-attenders through telephone, letters, electronic messages, and pharmacists.

Verbatim wording from the response

“There is currently a system in place whereby patients on repeat medications are notified that they ought to make an appointment for a medication review on their reorder form when they request a prescription. There is a “counting down” procedure each time they request a repeat prescription. Patients that repeatedly ignore this are being contacted by telephone or letter asking them to make a medication review appointment or a message asking them to make an appointment is added to their electronic prescription. As part of our investigations, we have contacted local pharmacists and asked them to ensure that the messages are duly passed on to patients.”

Source location

2015-0392-Response
Page 2 · response
Published 28 September 2015

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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 all patients taking SSRI antidepressants invitations to medication reviews with information about antidepressants and stopping treatment.

Verbatim wording from the response

“As part of improving our management of patients on SSRI antidepressants, partners agreed that we would write to all such patients to invite them to attend for a medication review and provide additional information about coming off antidepressants and about SSRI antidepressants generally. A copy of the letter is enclosed for information.”

Source location

2015-0392-Response
Page 2 · response
Published 28 September 2015

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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

Advise patients taking SSRI antidepressants to have an annual medication review during their birthday month.

Verbatim wording from the response

“As an additional measure, patients are also being advised to have an annual medication review in the month of their birthday.”

Source location

2015-0392-Response
Page 2 · response
Published 28 September 2015

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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

Repeat-audit SSRI antidepressant patients due medication reviews and assess identified patients individually over six months as resources permit.

Verbatim wording from the response

“A repeat audit of patients on SSRI antidepressants was performed in October 2015. This consisted of a computer database search of such patients who are due to have a medication review. These patients are being considered on a case by case basis over the next 6 months as resources permit.”

Source location

2015-0392-Response
Page 2 · response
Published 28 September 2015

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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

Document follow-up arrangements, counselling or CBT offers, patient decisions, and arrangements following acceptance when starting antidepressants.

Verbatim wording from the response

“It was also agreed that when starting antidepressants, clear follow up arrangements should be documented. It should also be documented that counselling/CBT has been offered and it should also be clearly documented as to whether the offer was accepted or declined. If accepted, the relevant arrangements should be clearly documented.”

Source location

2015-0392-Response
Page 2 · response
Published 28 September 2015

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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

Existing surgery systems are considered robust and sufficient to ensure medication reviews and counselling offers for patients taking SSRI antidepressants.

Verbatim wording from the response

“The partners have taken substantial additional steps to address the points raised and are confident that there is a robust system in place at the surgery to ensure appropriate medication reviews and the offer of counselling to all patients taking SSRI antidepressants.”

Source location

2015-0392-Response
Page 3 · response
Published 28 September 2015

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Make information about accessing counselling readily available in the surgery waiting room.

    Stated by Partners at New Court SurgeryStated completedThe respondent said that this action was complete when they made their response on 28 September 2015.
  2. 2

    Warn patients starting SSRI antidepressants about suicidal feelings, advise discussion with family or friends, and document this advice in patient records.

    Stated by Partners at New Court SurgeryStated plannedThe respondent said that this action was planned when they made their response on 28 September 2015.

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

Make information about accessing counselling readily available in the surgery waiting room.

Verbatim wording from the response

“We have also made available information on how to access counselling in the waiting room in order that such information is readily accessible to patients.”

Source location

2015-0392-Response
Page 2 · response
Published 28 September 2015

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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

Warn patients starting SSRI antidepressants about suicidal feelings, advise discussion with family or friends, and document this advice in patient records.

Verbatim wording from the response

“During the significant event review meeting, it was agreed that when a patient is started on SSRI antidepressants, they would be warned of the possible development of suicidal feelings and what to do should this occur. It was discussed that patients should also be requested to discuss their condition and treatment with family/friends who may be able to then spot negative mood changes and/or suicidal thoughts. Awareness has been raised with the doctors to document this clearly in the patient records.”

Source location

2015-0392-Response
Page 2 · response
Published 28 September 2015

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026