PFD report

Olivia Amy RUSSELL · Prevention of Future Deaths report

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Issued 14 Dec 2023•Cheshire

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. Delays in conducting significant event reviews after deaths
    Part of recurring concern: Failure to learn from deaths through systematic review
  2. Failure to routinely discuss medication relapse and worsening risks with patients
    Part of recurring concern: Failure to communicate clinically significant medication risks to patientsPart of recurring concern: Inadequate assessment of causes and risks of mental health relapse
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.7

  1. Action

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

    Stated by Stretton Medical CentreStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.
  2. Action

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

    Stated by Stretton Medical CentreStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.
  3. Action

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

    Stated by Stretton Medical CentreStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.

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

Delays in conducting significant event reviews after deaths

Wider context from the report

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

Is this part of a recurring concern?

Yes — Failure to learn from deaths through systematic review.

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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

Failure to routinely discuss medication relapse and worsening risks with patients

Wider context from the report

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

Is this part of a recurring concern?

Yes — Failure to communicate clinically significant medication risks to patients; Inadequate assessment of causes and risks of mental health relapse.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

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

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

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

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

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

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct a Significant Event Analysis of Olivia’s death to identify learning and required system or practice changes.

Verbatim wording from the response

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

Source location

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

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

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

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

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

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

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

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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.3

  1. 1

    Share the death-related learning with all practice clinicians and submit it to primary care network clinicians for peer review.

    Stated by Stretton Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 28 December 2023.
  2. 2

    Arrange a follow-up appointment and contact patients who do not attend their appointment using ACCURX messaging or telephone calls.

    Stated by Stretton Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 28 December 2023.
  3. 3

    Arrange appropriate two-week and four-week medication reviews for patients commencing medication for anxiety or depression.

    Stated by Stretton Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 28 December 2023.

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 death-related learning with all practice clinicians and submit it to primary care network clinicians for peer review.

Verbatim wording from the response

“A SEA was conducted on 2 January 2024. The Practice accepts that an SEA should have been performed sooner and prior to the inquest to ensure that learning from the death was identified as soon as possible and changes made to systems or practice where required. This was an oversight on our part, and the Practice would like to apologise for the delay. This learning is shared with all the clinicians in our practice and will be shared with clinicians in our primary care network for peer review.”

Source location

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

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Arrange a follow-up appointment and contact patients who do not attend their appointment using ACCURX messaging or telephone calls.

Verbatim wording from the response

“We will arrange a follow-up appointment for any patients that DNA (did not attend) their appointment, with an ACCURX text message or a call when unable to send ACCURX text message.”

Source location

Response from Stretton Branch Surgery
Page 4 · response
Published 28 December 2023

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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

Arrange appropriate two-week and four-week medication reviews for patients commencing medication for anxiety or depression.

Verbatim wording from the response

“The Practice have agreed to book a review with the patient two weeks later where appropriate if medication has been commenced in relation to anxiety or depression symptoms. This should be then followed up with a medication review after 4 weeks where appropriate.”

Source location

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

Open published response
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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