Margaret Pegnall
31 Dec 2015 · Coroner Jacqueline Lake · Norfolk
The coroner's concerns
1. patient's call not escalated
“Mrs [name redacted] went to see her GP on 19 January and 12 March 2015 regarding difficulties she was having with her husband. The GP asked questions with regard to depression using a Flowchart attached to the Surgery's Policy on Domestic Violence and Abuse. Mrs [name redacted] wrote letters to the Practice referring to her interaction with the Police. Mrs [name redacted] telephoned the Practice on the-day of her death asking to speak fo a particular GP who was absent requesting”
2. vague domestic abuse flowchart
“The Flowchart for Responding to Domestic Abuse is vague and uses an Assessment of Risk pertaining to.depression and not to the risk of abuse”
3. no domestic abuse questionnaire
“There is no Questionnaire specific to Domestic Abuse to assist in recognising signs of abuse and standardising the Surgery's:GPs' response to concerns raised”
4. no escalation method
“There was no method available to members of staff to recognise when a patient's call should be escalated and dealt with immediately”