Matthew Evans
18 May 2022 · Coroner Karen Henderson · Surrey
The coroner's concerns
1. lack of proactive care
“The GP was not sufficiently proactive with multiple lost opportunities to provide better care and support for [the deceased]”
2. absence of prescribing policy
“No policy was provided to assist GP's with prescribing of Mirtazapine and antidepressants and anxiolytics in general practice”
3. inadequate referral guidance
“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”
Responses
2022-0148-Response-from-Care-Quality-Commisson.pdf ↗· Care Quality Commission
2022-0148-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2022-0148-Response-from-Farnham-Practice.pdf ↗· Surrey Clinical Commissioning Group, GP and Farnham Park GP Practice
2022-0148-Response-from-General-Medical-Council2.pdf ↗· General Medical Council
2022-0148-Response-from-NHS-England.pdf ↗· NHS England
Stated action
“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.”
2022-0148-Response-from-NHS-Firmley.pdf ↗· Surrey Clinical Commissioning Group, GP and Farnham Park GP Practice
Stated action · July 2022
“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.”