Report evidence summary
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. 21
Action
Provide the report to Regional Mortality Boards for dissemination to all Integrated Care Boards to support learning from the event.
Stated by NHS England Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source
Action
Add clearer initiation advice requiring discussion of possible worsening depression and increased suicidal thoughts for relevant patients receiving new antidepressants.
Stated by NHS Frimley ICB Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source
Action
Develop a point-of-prescribing alert reminding prescribers about national guidance on increased risk in young people.
Stated by NHS Frimley ICB Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source
Action
Share suicide and self-harm documentation and assessment learning with all Frimley GP practices through bulletins, meetings, clinical leads and prescribing updates.
Stated by NHS Frimley ICB Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source
Action
Deliver a recorded virtual training session on mental health assessment and documentation, then distribute the recording to all practices.
Stated by NHS Frimley ICB Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source
Action
Remind local prescribers about the clearer antidepressant-initiation advice through ICB communication channels.
Stated by NHS Frimley ICB Stated in progressThe respondent said that this action was in progress when they made their response on 19 May 2022. View source
Action
Request Serious Event Audits from practices and review whether learning points from suicide investigations have been considered.
Stated by NHS Frimley ICB Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source
Action
Update the local formulary to highlight national guidance on increased suicidal behaviour risk after antidepressant initiation.
Stated by NHS Frimley ICB Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source
Action
Send PHQ9 and GAD7 questionnaires before consultations and record their scores directly in EMIS Web.
Stated by Farnham Park Health Group and Recipient name withheld 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 by Farnham Park Health Group and Recipient name withheld 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 by Farnham Park Health Group and Recipient name withheld 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 by Farnham Park Health Group and Recipient name withheld 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 by Farnham Park Health Group and Recipient name withheld 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 by Farnham Park Health Group and Recipient name withheld 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 by Farnham Park Health Group and Recipient name withheld 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 by Farnham Park Health Group and Recipient name withheld 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 by Farnham Park Health Group and Recipient name withheld 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 by Farnham Park Health Group and Recipient name withheld 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 by Farnham Park Health Group and Recipient name withheld 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 by Farnham Park Health Group and Recipient name withheld 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 by Farnham Park Health Group and Recipient name withheld Stated completedThe respondent said that this action was complete when they made their response on 19 May 2022. View source See 18 more actions Respondent positions A position is what a recipient says about a concern when it does not describe a specific action. 18
Position
NHS commissioners are responsible for assuring provider serious-incident investigations, overseeing action plans, and closing incidents.
Stated by NHS England Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
Remote consultations during the COVID-19 pandemic were consistent with NHS England guidance, although face-to-face appointments were required from May 2021.
Stated by NHS England Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
Existing NICE, Clinical Knowledge Summaries, BNF, GP training and continuing professional development sufficiently support depression assessment and prescribing without a separate policy.
Stated by NHS England Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
The circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Stated by Care Quality Commission Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Stated by Care Quality Commission Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Regulatory action can target registered managers or providers, but not failings attributed solely to individuals.
Stated by Care Quality Commission Outside remitThe respondent said that this matter was outside its role or authority. View source
Position
Prescribing decisions are assigned to the responsible clinician, who must consider the patient’s needs, guidance and local commissioning decisions.
Stated by Department of Health and Social Care Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
Existing clinical guidance, professional standards, revalidation and training arrangements are considered sufficient to support appropriate prescribing and diagnosis.
Stated by Department of Health and Social Care Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
The GP’s prescribing choices were in line with guidance, despite identified risks associated with antidepressants.
Stated by NHS Frimley ICB Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Stated by General Medical Council No action considered necessaryThe respondent said that no further action was needed. View source
Position
The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Stated by General Medical Council Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
The Practice disputes that the death was not investigated or reviewed, stating that it was discussed promptly and later subjected to significant event analysis.
Stated by Farnham Park Health Group and Recipient name withheld Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
Face-to-face consultation was not offered because pandemic advice was to avoid face-to-face appointments where possible.
Stated by Farnham Park Health Group and Recipient name withheld Unable to actThe respondent said that a constraint prevented them from taking the relevant action. View source
Position
The Practice concluded that the prescribed medication was appropriate because insomnia was the patient's original primary reason for contacting it.
Stated by Farnham Park Health Group and Recipient name withheld Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
The GP disputes that no mental health risk assessment occurred, stating that he asked about suicidal ideation and self-harm.
Stated by Farnham Park Health Group and Recipient name withheld Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
The Practice relied on NICE recommendations, BNF information and NICE CKS guidance despite there being no specific CCG prescribing guideline.
Stated by Farnham Park Health Group and Recipient name withheld Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
The response disputes that secondary mental health referral was indicated, stating that the patient did not meet referral criteria and remained low risk.
Stated by Farnham Park Health Group and Recipient name withheld Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
The audit disputed uncertainty about whether TalkPlus letters were read, confirming that all three were read within recorded timeframes.
Stated by Farnham Park Health Group and Recipient name withheld Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source See 17 more positions
× 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 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. Response links show a clear evidence connection; they do 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.
” Is this part of a recurring concern? Yes — Unreliable mental health referral pathways .
Open source report × 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 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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.
” Is this part of a recurring concern? Yes — Unsafe medication prescribing .
Open source report × 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 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.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × 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 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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. Response links show a clear evidence connection; they do 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.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
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 Provide the report to Regional Mortality Boards for dissemination to all Integrated Care Boards to support learning from the event.
Verbatim wording from the response “This report will be provided to the Regional Mortality Boards so that they may share it with all ICBs to ensure that they are able to learn from this event.” Source location Response from NHS England
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 Add clearer initiation advice requiring discussion of possible worsening depression and increased suicidal thoughts for relevant patients receiving new antidepressants.
Verbatim wording from the response “The prescribing choices undertaken by the GP were in line with guidance: prioritising non-pharmacological support for people with insomnia, providing a short course of zopiclone when essential; and prescribing mirtazapine for depression where there is also significant insomnia. However, we are undertaking additional steps to provide clearer advice at initiation of a new antidepressant. This will state that highlighting the potential for worsening depressive symptoms and increasing suicidal ideas is a key step that should be undertaken in every relevant case. This will happen on 12th July 2022 following approval from the medicine optimisation committee. Local prescribers will be reminded of this via our communication channels. This is happening through July and August 2022.” Source location Response from NHS Firmley
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 Develop a point-of-prescribing alert reminding prescribers about national guidance on increased risk in young people.
Verbatim wording from the response “Across Frimley there is an evidence-based formulary the production of which is supported by a multidisciplinary team and this details prescribing practices that are routinely used in the area. After reviewing this case, we have considered that although there are also a number of national publications that highlight the increased risk of suicidal behaviour for a patient initiated on antidepressants (for example, the BNF, MHRA and NICE) the risks should be further highlighted on the local formulary. Action will be taken to ensure that the local formulary highlights the national guidance more acutely, in addition to the currently available information. Furthermore, the development of a point of prescribing alert will be undertaken to ensure that prescribers are reminded about the national guidance relating to potential increased risk in young people.” Source location Response from NHS Firmley
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 suicide and self-harm documentation and assessment learning with all Frimley GP practices through bulletins, meetings, clinical leads and prescribing updates.
Verbatim wording from the response “The NHS Frimley ICB will be carrying out a number of actions following the inquest. These include sharing the concerns raised with all GP practices in the Frimley area. The learning will focus particularly on the importance of good documentation in recording risk of suicide or self-harm following a consultation when someone has been assessed as having suicidal ideation or is at risk of acts of self-harm.” Source location Response from NHS Firmley
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 Deliver a recorded virtual training session on mental health assessment and documentation, then distribute the recording to all practices.
Verbatim wording from the response “The practices across the ICS will also be reminded of the importance of a good mental health assessment using recognised mental health tools. There are already templates for PHQ9 and GAD on the GP systems for them to use. The learning will be shared with practices in July 2022 in the GP bulletin. In September 2022, there will be a virtual training session, which will be recorded, on mental health assessment, which will also include documentation. The recording will be sent to all practices following the event.” Source location Response from NHS Firmley
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 local prescribers about the clearer antidepressant-initiation advice through ICB communication channels.
Verbatim wording from the response “The prescribing choices undertaken by the GP were in line with guidance: prioritising non-pharmacological support for people with insomnia, providing a short course of zopiclone when essential; and prescribing mirtazapine for depression where there is also significant insomnia. However, we are undertaking additional steps to provide clearer advice at initiation of a new antidepressant. This will state that highlighting the potential for worsening depressive symptoms and increasing suicidal ideas is a key step that should be undertaken in every relevant case. This will happen on 12th July 2022 following approval from the medicine optimisation committee. Local prescribers will be reminded of this via our communication channels. This is happening through July and August 2022.” Source location Response from NHS Firmley
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 Request Serious Event Audits from practices and review whether learning points from suicide investigations have been considered.
Verbatim wording from the response “Practices will also be reminded of the importance of completing Serious Event Audits for serious/unexpected incidents. The NHS Frimley ICB quality team will be requesting the Serious Event Audits from practices as part of the investigation into suicides recorded as part of the NHSE” Source location Response from NHS Firmley
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 Update the local formulary to highlight national guidance on increased suicidal behaviour risk after antidepressant initiation.
Verbatim wording from the response “Across Frimley there is an evidence-based formulary the production of which is supported by a multidisciplinary team and this details prescribing practices that are routinely used in the area. After reviewing this case, we have considered that although there are also a number of national publications that highlight the increased risk of suicidal behaviour for a patient initiated on antidepressants (for example, the BNF, MHRA and NICE) the risks should be further highlighted on the local formulary. Action will be taken to ensure that the local formulary highlights the national guidance more acutely, in addition to the currently available information. Furthermore, the development of a point of prescribing alert will be undertaken to ensure that prescribers are reminded about the national guidance relating to potential increased risk in young people.” Source location Response from NHS Firmley
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 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
×
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 NHS commissioners are responsible for assuring provider serious-incident investigations, overseeing action plans, and closing incidents.
Verbatim wording from the response “c) 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 NHS England
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 Remote consultations during the COVID-19 pandemic were consistent with NHS England guidance, although face-to-face appointments were required from May 2021.
Verbatim wording from the response “c) The GP did not offer a face-to-face consultation” Source location Response from NHS England
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 Existing NICE, Clinical Knowledge Summaries, BNF, GP training and continuing professional development sufficiently support depression assessment and prescribing without a separate policy.
Verbatim wording from the response “a) No policy was provided to assist GP’s with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice” Source location Response from NHS England
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 circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Verbatim wording from the response “We are satisfied, at this point, that the circumstances surrounding Mr Evans’ death were a specific case and not indicative of widespread poor care on the part of the provider. Whilst we have concluded that improvements could have been made in the care and treatment provided to Mr Evans, this was not unsafe. We are pleased to see the provider has identified areas of improvement in its care and treatment, and we are assured that the actions taken will protect others using the service from harm. At this stage we have decided not to instigate any further action. However, we will continue to regularly monitor the provider and, where” Source location Response from Care Quality Commisson
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 No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Verbatim wording from the response “We are satisfied, at this point, that the circumstances surrounding Mr Evans’ death were a specific case and not indicative of widespread poor care on the part of the provider. Whilst we have concluded that improvements could have been made in the care and treatment provided to Mr Evans, this was not unsafe. We are pleased to see the provider has identified areas of improvement in its care and treatment, and we are assured that the actions taken will protect others using the service from harm. At this stage we have decided not to instigate any further action. However, we will continue to regularly monitor the provider and, where” Source location Response from Care Quality Commisson
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 Regulatory action can target registered managers or providers, but not failings attributed solely to individuals.
Verbatim wording from the response “As you may be aware, CQC can only take regulatory action against a registered manager or a registered provider, but not when failings of an individual have been identified.” Source location Response from Care Quality Commisson
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 Prescribing decisions are assigned to the responsible clinician, who must consider the patient’s needs, guidance and local commissioning decisions.
Verbatim wording from the response “You also raised concerns about the lack of policy to assist GPs with prescribing Mirtazapine, antidepressants and anxiolytics. The decision to prescribe a particular drug is a clinical one and should be based on the patient’s medical needs. Decisions about what medicines to prescribe are made by the doctor or healthcare professional responsible for that part of the patient’s care and prescribers are accountable for their prescribing decisions, both professionally and to their service commissioners. It is for the GP or other responsible clinician to work with their patient and decide on the course of treatment, with the provision of the most appropriate care for the individual always being the primary consideration.” Source location Response from Department of Health and Social Care
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 Existing clinical guidance, professional standards, revalidation and training arrangements are considered sufficient to support appropriate prescribing and diagnosis.
Verbatim wording from the response “As noted by NHS England, there are several educational resources and guidance documents relating to the assessment and treatment of depression that are regularly reviewed and accessible to clinicians. These include National Institute for Health and Care Excellence (NICE) guidance, which details possible adverse effects of prescribing mirtazapine, Clinical Knowledge Summaries and the British National Formulary.” Source location Response from Department of Health and Social Care
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’s prescribing choices were in line with guidance, despite identified risks associated with antidepressants.
Verbatim wording from the response “The prescribing choices undertaken by the GP were in line with guidance: prioritising non-pharmacological support for people with insomnia, providing a short course of zopiclone when essential; and prescribing mirtazapine for depression where there is also significant insomnia. However, we are undertaking additional steps to provide clearer advice at initiation of a new antidepressant. This will state that highlighting the potential for worsening depressive symptoms and increasing suicidal ideas is a key step that should be undertaken in every relevant case. This will happen on 12th July 2022 following approval from the medicine optimisation committee. Local prescribers will be reminded of this via our communication channels. This is happening through July and August 2022.” Source location Response from NHS Firmley
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 No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Verbatim wording from the response “The AR is assured that the matters contained in your complaint do not raise concerns that ████████ poses either a risk to patients or undermines the public’s confidence in doctors. Although we do not need to investigate further, we will share your concerns with the doctor’s responsible officer and ask the doctor to discuss it with their appraiser as part of their revalidation.” Source location Response from General Medical Council(2)
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 concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Verbatim wording from the response “The AR is assured that the matters contained in your complaint do not raise concerns that ████████ poses either a risk to patients or undermines the public’s confidence in doctors. Although we do not need to investigate further, we will share your concerns with the doctor’s responsible officer and ask the doctor to discuss it with their appraiser as part of their revalidation.” Source location Response from General Medical Council(2)
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
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. 15 1 Convene a Performance Advisory Group to direct investigatory and advisory work concerning the practitioner.
Stated by NHS England Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source 2 Refer Farnham Park GP to the NHS England South East Professional Standards team under the Responding to Concerns framework.
Stated by NHS England Stated completedThe respondent said that this action was complete when they made their response on 19 May 2022. View source 3 Continue regularly monitoring the provider to ensure patients receive a safe service.
Stated by Care Quality Commission Stated in progressThe respondent said that this action was in progress when they made their response on 19 May 2022. View source 4 Consider whether further regulatory action is needed to address the provider’s failure to notify the death promptly.
Stated by Care Quality Commission Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source 5 Meet with both providers to support development of their action plans.
Stated by NHS Frimley ICB Stated completedThe respondent said that this action was complete when they made their response on 19 May 2022. View source 6 Share the Regulation 28 report with the ICS Mortality Review and Quality Surveillance Groups for assurance on delivery.
Stated by NHS Frimley ICB Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source 7 Monitor TalkPlus compliance through the contractual route.
Stated by NHS Frimley ICB Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source 8 Place the practice on the ICB concerns framework for close patient-safety monitoring and subsequently review it through quality and primary-care teams.
Stated by NHS Frimley ICB Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source 9 Review provider and practice action plans through the ICB quality team.
Stated by NHS Frimley ICB Stated in progressThe respondent said that this action was in progress when they made their response on 19 May 2022. View source 10 Monitor the actions quarterly across the ICB, practices and TalkPlus.
Stated by NHS Frimley ICB Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source 11 Ask the doctor to discuss the concerns with their appraiser during revalidation.
Stated by General Medical Council Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source 12 Share the concerns with the doctor’s responsible officer.
Stated by General Medical Council Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source 13 Attend MDU training on clinical record keeping and maintain familiarity with GMC record-keeping guidance.
Stated by Farnham Park Health Group and Recipient name withheld Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source 14 Document safety-netting advice in EMIS Web whenever it is given.
Stated by Farnham Park Health Group and Recipient name withheld Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source 15 Reflect on the care and coroner’s concerns in appraisal and the personal development plan.
Stated by Farnham Park Health Group and Recipient name withheld Stated plannedThe respondent said that this action was planned when they made their response on 19 May 2022. View source Recipient positions A position is what a recipient says about a concern when they do not describe a specific action. 3 1 The Performance Advisory Group will direct investigatory and advisory work concerning the practitioner and consider any additional actions.
Stated by NHS England Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source 2 The GP disputes that he was insufficiently proactive, stating that he suggested alternatives rather than prescribing a sleeping tablet.
Stated by Farnham Park Health Group and Recipient name withheld Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source 3 The GP was not responsible for deciding when CBT patients progressed to high-intensity treatment; he could only refer them.
Stated by Farnham Park Health Group and Recipient name withheld Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
×
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 Convene a Performance Advisory Group to direct investigatory and advisory work concerning the practitioner.
Verbatim wording from the response “The NHS England Kent, Surrey and Sussex regional team will be convening a Performance Advisory Group (PAG) as part of NHS England » Responding to concerns procedures. A PAG is a small, local panel of people who are tasked with carrying out or directing the scope of investigatory and advisory work relating to concerns about doctors on the Performers Lists. Any additional actions arising to address concerns of the practitioner will be considered further in the PAG.” Source location Response from NHS England
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 Refer Farnham Park GP to the NHS England South East Professional Standards team under the Responding to Concerns framework.
Verbatim wording from the response “In response to receiving your Report, NHS England has taken action to refer Farnham Park GP to NHS England South East region’s Professional Standards team, under NHS England’s ‘Responding to Concerns’ framework and any additional actions arising that are required to address the concerns of the coroner, will be overseen and followed though by the NHS England South East region’s Professional Advisory Group.” Source location Response from NHS England
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 Continue regularly monitoring the provider to ensure patients receive a safe service.
Verbatim wording from the response “We are satisfied, at this point, that the circumstances surrounding Mr Evans’ death were a specific case and not indicative of widespread poor care on the part of the provider. Whilst we have concluded that improvements could have been made in the care and treatment provided to Mr Evans, this was not unsafe. We are pleased to see the provider has identified areas of improvement in its care and treatment, and we are assured that the actions taken will protect others using the service from harm. At this stage we have decided not to instigate any further action. However, we will continue to regularly monitor the provider and, where” Source location Response from Care Quality Commisson
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 Consider whether further regulatory action is needed to address the provider’s failure to notify the death promptly.
Verbatim wording from the response “Please also be advised our records showed we were not notified of Mr Evans’ death by the registered provider, as was legally required. This failure to report was immediately raised with the provider and we have since received this information. In accordance with our regulatory processes, consideration will now be given as to whether further action is needed to address this breach of regulation for failing to notify us in a timely way.” Source location Response from Care Quality Commisson
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 Meet with both providers to support development of their action plans.
Verbatim wording from the response “The Regulation 28 Report will also be shared with the ICS Mortality Review Group and ICS Quality Surveillance Group for assurance on delivery in August 2022. The actions will then be monitored quarterly from the ICB, Practice and Talk Plus. The NHS Frimley ICB quality team will also be reviewing the action plan with the provider and the Practice. The Practice will be put on the NHS Frimley ICB concerns framework for close monitoring on patient safety while their actions are in progress and then this will be reviewed by the NHS Frimley ICB quality and primary care teams. TalkPlus will be monitored against compliance through the contractual route. The NHS Frimley ICB has already met with both providers to work with them on their action plans, these meetings occurred in June 2022.” Source location Response from NHS Firmley
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 Regulation 28 report with the ICS Mortality Review and Quality Surveillance Groups for assurance on delivery.
Verbatim wording from the response “The Regulation 28 Report will also be shared with the ICS Mortality Review Group and ICS Quality Surveillance Group for assurance on delivery in August 2022. The actions will then be monitored quarterly from the ICB, Practice and Talk Plus. The NHS Frimley ICB quality team will also be reviewing the action plan with the provider and the Practice. The Practice will be put on the NHS Frimley ICB concerns framework for close monitoring on patient safety while their actions are in progress and then this will be reviewed by the NHS Frimley ICB quality and primary care teams. TalkPlus will be monitored against compliance through the contractual route. The NHS Frimley ICB has already met with both providers to work with them on their action plans, these meetings occurred in June 2022.” Source location Response from NHS Firmley
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 Monitor TalkPlus compliance through the contractual route.
Verbatim wording from the response “The Regulation 28 Report will also be shared with the ICS Mortality Review Group and ICS Quality Surveillance Group for assurance on delivery in August 2022. The actions will then be monitored quarterly from the ICB, Practice and Talk Plus. The NHS Frimley ICB quality team will also be reviewing the action plan with the provider and the Practice. The Practice will be put on the NHS Frimley ICB concerns framework for close monitoring on patient safety while their actions are in progress and then this will be reviewed by the NHS Frimley ICB quality and primary care teams. TalkPlus will be monitored against compliance through the contractual route. The NHS Frimley ICB has already met with both providers to work with them on their action plans, these meetings occurred in June 2022.” Source location Response from NHS Firmley
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 Place the practice on the ICB concerns framework for close patient-safety monitoring and subsequently review it through quality and primary-care teams.
Verbatim wording from the response “The Regulation 28 Report will also be shared with the ICS Mortality Review Group and ICS Quality Surveillance Group for assurance on delivery in August 2022. The actions will then be monitored quarterly from the ICB, Practice and Talk Plus. The NHS Frimley ICB quality team will also be reviewing the action plan with the provider and the Practice. The Practice will be put on the NHS Frimley ICB concerns framework for close monitoring on patient safety while their actions are in progress and then this will be reviewed by the NHS Frimley ICB quality and primary care teams. TalkPlus will be monitored against compliance through the contractual route. The NHS Frimley ICB has already met with both providers to work with them on their action plans, these meetings occurred in June 2022.” Source location Response from NHS Firmley
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 provider and practice action plans through the ICB quality team.
Verbatim wording from the response “The Regulation 28 Report will also be shared with the ICS Mortality Review Group and ICS Quality Surveillance Group for assurance on delivery in August 2022. The actions will then be monitored quarterly from the ICB, Practice and Talk Plus. The NHS Frimley ICB quality team will also be reviewing the action plan with the provider and the Practice. The Practice will be put on the NHS Frimley ICB concerns framework for close monitoring on patient safety while their actions are in progress and then this will be reviewed by the NHS Frimley ICB quality and primary care teams. TalkPlus will be monitored against compliance through the contractual route. The NHS Frimley ICB has already met with both providers to work with them on their action plans, these meetings occurred in June 2022.” Source location Response from NHS Firmley
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 Monitor the actions quarterly across the ICB, practices and TalkPlus.
Verbatim wording from the response “The Regulation 28 Report will also be shared with the ICS Mortality Review Group and ICS Quality Surveillance Group for assurance on delivery in August 2022. The actions will then be monitored quarterly from the ICB, Practice and Talk Plus. The NHS Frimley ICB quality team will also be reviewing the action plan with the provider and the Practice. The Practice will be put on the NHS Frimley ICB concerns framework for close monitoring on patient safety while their actions are in progress and then this will be reviewed by the NHS Frimley ICB quality and primary care teams. TalkPlus will be monitored against compliance through the contractual route. The NHS Frimley ICB has already met with both providers to work with them on their action plans, these meetings occurred in June 2022.” Source location Response from NHS Firmley
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 Ask the doctor to discuss the concerns with their appraiser during revalidation.
Verbatim wording from the response “The AR is assured that the matters contained in your complaint do not raise concerns that ████████ poses either a risk to patients or undermines the public’s confidence in doctors. Although we do not need to investigate further, we will share your concerns with the doctor’s responsible officer and ask the doctor to discuss it with their appraiser as part of their revalidation.” Source location Response from General Medical Council(2)
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 concerns with the doctor’s responsible officer.
Verbatim wording from the response “The AR is assured that the matters contained in your complaint do not raise concerns that ████████ poses either a risk to patients or undermines the public’s confidence in doctors. Although we do not need to investigate further, we will share your concerns with the doctor’s responsible officer and ask the doctor to discuss it with their appraiser as part of their revalidation.” Source location Response from General Medical Council(2)
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 MDU training on clinical record keeping and maintain familiarity with GMC record-keeping guidance.
Verbatim wording from the response “17. ████████ has identified training provided by MDU Serviced Limited which he shall attend, on record keeping, the date for the next course is yet to be confirmed. He has already refamiliarized himself with the GMC Good Medical Practice guidance on record keeping by way of reminder of the standards expected.” 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 Document safety-netting advice in EMIS Web whenever it is given.
Verbatim wording from the response “19. Safety netting advice must be documented in EMIS Web when given.” 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 Reflect on the care and coroner’s concerns in appraisal and the personal development plan.
Verbatim wording from the response “14. He will be reflecting on the care and concerns raised by H.M. Coroner in his Appraisal and Personal Development Plan.” 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 Performance Advisory Group will direct investigatory and advisory work concerning the practitioner and consider any additional actions.
Verbatim wording from the response “In response to receiving your Report, NHS England has taken action to refer Farnham Park GP to NHS England South East region’s Professional Standards team, under NHS England’s ‘Responding to Concerns’ framework and any additional actions arising that are required to address the concerns of the coroner, will be overseen and followed though by the NHS England South East region’s Professional Advisory Group.” Source location Response from NHS England
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 he was insufficiently proactive, stating that he suggested alternatives rather than prescribing a sleeping tablet.
Verbatim wording from the response ““The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for Matthew.”” 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 was not responsible for deciding when CBT patients progressed to high-intensity treatment; he could only refer them.
Verbatim wording from the response “5. This is the Response of ████████ and the Practice to the concerns raised in the Regulation 28 Report concerning both.” Source location Response from Farnham Practice
Open published response
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