Dear Ms Voisin, Prevention of Future Death Response The Trust welcomes the opportunity to respond to the issue you have raised through the Regulation 28 report Prevention of Future Deaths report; in connection with the death of Ms Natasha Abrahart. We are determined to improve the safety of our services for patients and families following this tragic death. In response to the report; the Trust has taken the following steps. We have distributed a Red Top Alert via our Trust-wide alerting system instructing all medical personnel, all non-medical prescribers, all pharmacists and all team mangers to be ensure that prescribers follow the NICE Guidance in relation to the prescribing of anti-depressants (CG9O): The instruction includes a requirement to adhere to the guidance and makes clear the responsibility to communicate effectively with primary care about which individual will undertake the review at seven days; and that this must be clearly documented: There is a robust auditable system which demands a response from all the teams circulated in the alert; permitting the identification of any gaps There will be an obligation for medical leads to discuss this with all their line reports, to ensure effective communication of this alert: In addition to the alert; this will also be raised at various fora across the Trust; ensuring that the learning from this tragic death is shared as widely and comprehensively as possible. These include: Medical Leads Meeting on the agenda at the next meeting 16th July 2019 Trust-wide Medical Advisory Group (TMAG) September 2019 The Learning from Experience Meeting meeting that shares learning from experience across the Trust on the agenda for the next meeting 17th July 2019 The Medicines Optimisation Group (MOG) a Trust-wide meeting chaired by the Chief Pharmacist on the agenda for the next meeting 23rd 2019 Please find attached, as an appendix; the Red Alert circulated through our patient safety alert system. Chief Chair Trust Headquarters Executive Charlotte Hitchings Bath NHS House; Newbridge Hill; Bath BA1 3QE Simon Truelove July Top Acting

hope the information provided indicates how seriously the Trust has taken the death of Ms Abrahart and how committed we are to embedding the learning, improving patient safety and reducing avoidable If there is any further information you require we would be happy to provide this:

From Jackie Doyle-Price MP Parliamentary Under Secretary of State for Mental Health, Department Inequalities and Suicide Prevention of Health & Social Care 39 Victoria Street London SWIH OEU 020 7210 4850 Your Ref: 10686 Our Ref: PFD-1178625 Ms Maria Voisin HM Senior Coroner; Avon HM Coroner's Court The Courthouse Old Weston Road Flax Bourton BS48 IUL July 2019 Sea Ma Thank you for your correspondence of 16 to Matt Hancock and myself about the death of Ms Natasha Abrahart. Firstly, would like to say how sorry I was to read of the circumstances of Natasha'$ death: I can appreciate how distressing her loss, at such a young age, must be for her family and loved ones and would like to offer my sincerest condolences. We must do all we can to Iearn from deeply regrettable incidents such as these to prevent future deaths. We recognise the importance of identifying and treating depression in suicide prevention and welcome the guidelines by the National Institute for Health and Care Excellence (NICE) on the treatment and management of depression in adults (Clinical Guideline 90'), and the pathway guidance on anti-depressant treatment in adults_ Iam aware that Clinical Guideline 90 is currently being updated. While it is not appropriate to pre-empt the results of consultation on the update of the guideline, NICE advises that the core message of the recommendation around follow up after inle prescription of antidepressants is likely to remain. https Iwww nice Org uklguidancelcg90 Voou May "

The latest version ofthe update that NICE is consulting on reads:
1.4.17 When prescribing antidepressant medication for _ with depression who are under 30 years or are thought to be at increased risk of suicide: see them 1 week after starting the antidepressant medication review them aS often aS needed, but no later than 4 weeks after the first appointment base the frequency of review on their circumstances (for example, the availability of support, break-up of a relationship, loss of employment), and any changes in suicidal ideation or assessed risk of suicide. [2018] As you know, this guidance sets out preventative action for people at risk of suicide and we encourage the NHS to implement these guidelines Clinical guidelines represent best practice and should be taken fully into account by clinicians. You may wish to note that in October 2018, Health Education England (HEE) launched a suite of four Self Harm and Suicide Prevention Frameworks. The frameworks describe some of the important things that a skilled professional, or member of staff, needs to have to be able to support people who self-harm or have suicidal thoughts These frameworks highlight the importance of health professionals having the required knowledge of pharmaceutical interventions and, for those with prescribing rights, knowledge of the potential adverse effects of antidepressant medication, including possible increases in suicidal thoughts and behaviours The frameworks also highlight the importance of knowledge of national guidance, including NICE guidelines, for the treatment of people who self-harm andlor are suicidal that include recommendations regarding the role of medication. HEE is also undertaking a scoping exercise of existing suicide training provision to identify gaps, using the competency frameworks; to enable the development of an online compendium of training which will be freely accessible to all health professionals. As the Minister for Universities, Chris Skidmore MP, and [ advised when we jointly responded to you on a recent Prevention of Future Deaths Report issued following the inquest into the death of Mr Benjamin Murray, mental health and suicide prevention are priorities for this Government: https:ILwwwnice org uklguidancelindevelopmentlgid-cgwave0 2S/documents people key -

This Government has set out an ambitious programme of work to reduce suicides, including actions being taken to improve the mental health of university students; This ambition is set out in the first cross-Government Suicide Prevention Workplan published in January 20193. Several initiatives are being undertaken to promote best practice in the higher education sector and to support universities to adopt mental health as a strategic priority: In summary, this includes: Guidance 0n measures to help prevent suicide; *Suicide-Safer Universities4'
2018. All universities are expected to actively engage with the guidance to improve mental health support and reduce suicide risks amongst their student population; Funding investment in 10 projects encouraging higher education providers to find new ways of combating student mental health issues, including the development of links between higher education providers and local primary care and mental health servicess . Outcomes will be widely communicated across the sector; Elmillion extra funding announced by the Prime Minister in June 2019 for proposals to promote partnership working between the health and education sectors6; The University Mental Health Charter? , supported by the Government and led by the higher education sector to drive up standards in promoting student and staff mental health and wellbeing; and, Launch of the Education Transitions Network in March 20198 by the Department for Education which will be developing a strategic approach to supporting students when starting university and will provide advice on universities can better at involving support networks at an early stage when students are struggling; https:IIWWwsgoy uklgovernmentlpublications/suicide-prevention-cross-government-plan https:ILwWWuniversitiesuk ac ukIpolicy-and-analysis/reports/Pages/guidance-for-universities-on-preventing_-student- suicides aspx htps Iwwwofficeforstudents Org uknews-blog-and-eventskpress-and-medialinnovation-partnership-and-data-can- help_improve-student-mental-health-in-new_l4m-drivel https llwww govuklgoverument/newslpm-launches-new_mission-to-put-prevention-at-the-top-of-the-mental-health- agerda httpsILwwwgovuklgovernment-newslnew-package-of-measures-announced-on-student-mental-health https IIdfemediabloggov uk/2019/03/07thursday Z march-20L9-university-mental-healthl how get

[ hope this response demonstrates the Government'$ commitment to supporting student mental health and wellbeing and to the prevention of suicide. JACKIE DOYLE-PRICE

NJA University of BRISTOL
15.07.19 Regulation 28 responsc Thank you for giving US the opportunity to review this sensitive issue a8 a practice, and to report to you our plans moving forward a8 an attempt to prevent future deaths from suicide in our 'patient population. Background: The Students Health Service is a GP practice set within the University of Bristol and we serve population of around 21,000_ The majority of our patients are 18-25 years and we see high volume of mental health conditions aS part of our daily work as General Practitioners From our membership of the Student Health Association we arc aware that this is in line with the experience of other GP practices serving student populations. Our aim aS set out in our Mission Statement is to provide a unique and positive healthcare experience for students and their dependents We are aware of the increased risk of suicide within our population; and make daily difficult clinical judgements around individual risk and best to monitor and support Our patients Inquest case: Natasha Abrahart was seen by a GP from our practice on 20th April 2018,10 to her death: She was not at that time expressing suicidal ideation. She was restarted on an SSRI (Selective Serotonin Reuptake Inhibitor Antidepressant) and given a 14 day supply. There was a plan to revicw her at 14 with an for her to come back sooner if required. She was aware she could be sccn as an emergency in & same day appointment if necessary. Natasha was reviewed on 26th April 2018 by the secondary care recovery navigator responsible for her care, who booked further follow up with her on a weekly basis. She ended her life 3 later . In response: NICE review (National Institute for Health and Care Excellence) We have conducted a review of the guidance from NICE, and advice has been sought from the team at NICE who are involved in writing new draft guidance which is due to be published in 2020. Their response is as follows via _ Communications Executive, National Institute for Health and Care Excellence, 19/06/2019: [will respond t0 your queslions in reverse order. The evidence for the potential increased prevalence of suicidal thoughts in the early stages of antidepressant treatment for those younger than 30 years is summarised in section 1.10 of the full guideline (pp.462-465). Students' Health Service Hampton House Health Centre; St Michael"s Hill, Cotham Bristol BS6 6AU UK Tel: +44 (0)117 330 2577 Fax: +44 (0)117 330 2698 MB ChB, Head of Service JRGN, Nursing Team Manager JBA MlnstLM; Practice Manager bristolacuk/student-health aged how days prior days option days email

The draft version of the updated guideline on depression in adults: treatment and management that is currently in development (which was made publicly available for consultation last year , but which is now amended further) has the following very similar recommendation: When prescribing antidepressant medication for people with ession who are under 30 years or are thought to be at increased risk of suicide: see them week after starting the antidepressant medication review them aS often aS needed, but no later than 4 weeks after the first appointment base the frequency of review on their circumstances (for example, the availability of support, break-up of a relationship, loss of employment), and any changes in suicidal ideation or assessed risk of suicide. At this stage I cannot say whether this recommendation will be amended further before the final publication of the guideline. In terms of following NICE guidelines, they have always been guidance and not policy Or procedure. The Chair of NICE Sir David Haslam has been quoted as saying The mantra that Fve given in every lecture is that they re guidelines and not tramlines. Doctors have a fundamental responsibility to use guidclincs with their experience and with patients' individual needs to get the best possible overlap bctween patient-centred medicine and evidence-based medicine It'$ not eitherlor: Local CCG review (Clinical Commissioning Group) A review of the guidance from the local clinical commissioning group was also undertaken via the medicines management team at BNSSG CCG their guidance reads: https:Ilwww.bnssgformulary nhs uklincludes/documents/Prescribing%2Ofor%/2ODepression% 20v2%/2OMayl 6.pdf Assessment of suicide risk: Patients considered at risk of suicide or under 30 years old should be seen after one week and frequently until risk is considered no longer significant. All other patients should be seen after 2 weeks. All patients should be considered for and alcohol abuse Expert opinion Thank you to the Coroner for asking for clarification from the expert witness in the case, Dr around whether the face to face revicw at 7 should be done by a General Practitioner or by a member of the practice team. He has advised that the assessment of depressive symptoms and suicide risk at this stage could be undertaken by other suitably trained members of the clinical team e.g nurses; social workers They could then be supported by prescribing clinicians if a change needed to be made to antidepressants This advice is Page being depre being drug days

Page 3_ welcome a8 it informs how we respond as a service and how wc consider future service development and staffing: QOF The current QOF (Quality Outcomes Framework) for depression states that a depression interim review should be undertaken at 10-56 Having reviewed the guidance around treatment of depression we would suggest that changing the achievernent critecria within this QOF domain is a potential area for positive change A change to this time frame might improvc mental health outcomes across primary care, ifit were updated at national level to reflect best practice. We intend to feed this back to our ocal CCG in the near future Current position at Student Health Service: Every patient is considered on an individual basis and clinical treatment plans are put in place according to need and perceived risk of suicide and selfharm: This includes the use of safely plans and safety planning apps, both leaflet and text information about emergency numbers/crisis/Samaritanshwho to contact: We have daily dedicated same mental health appointments with the duty doctor for patients,with a mental health problem Or crisis We would also see any patient on the who felt needed assessment for their mental or physical health as an emergency_ These emergency mental health appointments are 20 minutes rather than the standard GP appointment of 10 minutes, as we appreciate may require more time in consultation. Patients are assessed mental health template at first presentation and this includes an assessment of their perceived suicide risk at the time. Suicidal ideation and selfharm are also routinely asked about at mental health follow up appointments, and at depression medication or other mental health medication reviews The template has been further amended to include a prompt on follow up after commencing SSRI patient thought to be at high or imminent risk of suicide would be referred as an emergency to Secondary Care Mental Health services using a referral form and a phone call to the AWP (Avon and Wiltshire Partnership) triage team We make clinical judgements around patient safety in the interim, and ifnecessary can direct the patient to a placc of safety such as the Accident and Emergency department at the hospital Patients who do not attend' (DNA) for appointments routinely have their notes reviewed and are sent & text with a standard message around missed appointments; If it is clear from the notes that the patient has mental health concerns and therefore may have missed the appointment due to their condition deteriorating, then additional efforts are made to contact the patient either a tailored text o task sent to the office team to contact the patient to rearrange the appointment: If there is no response to attempts to telephone them then a lctter may be sent. If there were significant concerns about the safety of a patient then & welfare check could be requested from local police. If consent was in place to liaise with University support services then we would consider contacting them t0 express Our concern: very days. day day they they using Any

Page 4_ Changes made: NA s death, We have added an adlditional lield on our Following the inquest touching upon and suieidlality: ~If' SSRI newly lirst health assessment template regarding SSRI wlien is follow prescrited: counsel re side cffects ad risk increasc suicidality initially: to Ihe concerns expressed within your Regulation 28 report; we have moved In response an SSRI routinely to week; if this is appointments to review palients when starting_ appointment in for the patient; and have this as a 'booked' O known managcable accordance wiih NICE guidance: appointment with the at the end of the The clinician ideally books the next under the follow up consultation. They placc a message on the appointment screen patient cancels it would (0 alert (hem that this was a mental health review If the appointment cevicwing clinician who could follow up appropriately. If the be obvious to the DNA s then & review of the notes would be undertaken see above additional funding from the University to advertise for a Since the inquest we have requested andl this bas been We are currently permanent Mental Health Nurse to join our (eam member of the team would Working on an advert and job descriplion; The job plan forfthis SSRI, at 7 under 30 thought to be at risk of suicide, or starting on include reviewing patients mental health advisory service and psychology team days. We are liaising with local partners; to plan how best to utilise this new resource committed to adhering to best practice wherever possible i0 As a practice we are with NICE and local guidelincs The inquest ensuring that our procedures are 'compliant to revicw systems in place alongside touching Natasha' s death has afforded us an opportunity consistent with guidance. We are confident that the changes described above are the relevant Jn future we will continue to monitor OUr systems at the local and national guidance. in accordance with these guidelines. to ensure we are providing care to Our (enkle memtal up?" patient patient agreed. and practice patients