Dear Dr Henderson Inquest into_the death of Miss Clare_Serena Anke Cooper RCGP response Thank you for your letter of 25 July addressed to] which has been passed t0 me. As Honorary Secretary of the College Council am the College Officer responsible for responding to Coroners' Regulation 28 Reports. was very sorry to hear of the death of Miss Cooper and the series of events leading up to it: set out below a brief description of the remit of the Royal College of General Practitioners and provide some detailed comments on the specific concerns you raise in your report: The role of_the College The Royal College of General Practitioners is a registered charity under Royal Charter and is the largest membership organisation in the United Kingdom solely for GPs Founded in 1952 , it has over 50,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline We are an independent professional body with enormous expertise in patient-centred generalist clinical care. Through our General Practice Foundation, established by the RCGP in 2009, we also maintain close links with other professionals working in General Practice, such as practice managers, practice nurses and physician assistants_ As well as running the postgraduate Membership examination (MRCGP) which is now required for doctors to qualify as GPs, the College also provides continuing professional development (CPD) for its members, and these continuing programmes are also available to non-members of the College: However, not all GPs are members of the College, and older GPs may never have joined. The General Medical Council holds the register of all who are considered able to practise as GPs, and it is to the GMC that revalidated doctors will be notified. Similarly, it is not for us to comment on the performance of any individual GP and the information set out below is solely to show you what we provide in the context of training and advice to our Members. RCGP Education and Training Currently all doctors wishing to follow a career in general practice in the UK are required to undergo a 3 year programme of vocational training for general practice, based on the College's GP Curriculum_ Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp.org uk Web WWw rcgp org uk Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106

(The curriculum forms the foundation for GP training and assessment across the UK, prior to taking the College's Membership Examination (MRCGP) and continues to be relevant to GPs throughout their career including preparation for revalidation) httpIIwWW rcgporg uklgp-training-and-examslgp curriculum-overview aspx The GP Curriculum sets out College expectations of the standard of care that a general practitioner should provide and will use references to the GP Curriculum as a basis for my response Comments on Coroner's concerns on the general practitioner_care provided to Miss Clare Cooper The underlying principle for a general practitioner's management of any patient should be one of "holistic care This is set out in the section of the GP Curriculum entitled "'the Consultation in Practice" where the following advice is set out: "As a GP you should:
6.4 Understand that consultations have a clinical, a psychological and a social component; with the relevance of each component varying from consultation to consultation (the 'triaxial' model)" give below detailed comments on the first six matters of concern you list in this particular case ,, ie those which directly relate to general practitioner care , setting aside your listed concerns 7 to 10 on which advice from hospital medicine will be more appropriate Poor GP documentation The College believes that sound recording systems and well organised record-systems are fundamental to good general practice and communications with fellow healthcare professionals outside the practice This expectation is out in the section of the GP Curriculum on A GP' http IwWW rcgporg uklgp-training-and-exams/~Imedia/Files/GP-training-and-exams/Curriculum 2012/RCGP-Curriculum-1-Being-a-GP ashx "As a GP you should_
1.2.3 Develop the clinical skills you need in history-taking, physical examination the use of ancillary tests for diagnosis" and "1.5.2 Develop your organisational skills for record-keeping, information management;, teamwork, running practice and auditing the quality of care' And again is highlighted in the section The Consultation in General Practice" where the GP is enjoined under criterion 1.6 to 'Effectively use patient records (electronic or paper) during the consultation to facilitate high-quality patient care and in 1.10 to "keep accurate, legible and contemporaneous records' The qualities required of the GP in information gathering and recording its importance for good patient care are further spelled out under the section Patient Safety and the Quality of Care" of the GP Curriculum: http IIwWW rcgp org Uklgp-training-and-exams/~Imedia/FilesIGP-training-and-examsICurriculum_ 2012/RCGP_Curriculum-2-02-Patient-Safety-and-Quality-Of-Care ashx refers: 'As a GP, you should: "Demonstrate an understanding of the connection between good data entry improved patient health outcomes
1.14 Demonstrate how to use information management and technology (IM&T) to share information and co-ordinate patient care with other health professionals
1.15 Demonstrate an understanding of the need for information recorded in the practice clinical system to be fit for sharing with different health professionals in different organisations Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgp org.uk Web WWw_rcgp.org uk Patron: Royal Highness the Duke of Edinburgh Registered charity number 223106 set 'Being and and and His

1.16 Demonstrate how to use NHS electronic booking systems to tailor healthcare provision to the needs of the individual patient
1.17 Demonstrate the use of the practice's computer system to improve the quality and usefulness of the medical record, e.g: through audit
1.18 Demonstrate effective use of interagency systems such as pathology links and GP_GP record transfer"
2. "Lack of evidence ofa robust assessment of_presenting signs and symptoms_ The following section of the GP Curriculum provides advice on the diagnosis of metabolic disorders http IlwWW Icgporg uklgp-training-and-examsk~ImedialFilesIGP-training-and-exams/Curriculum 2012/RCGP-Curriculum-3-17-Metabolic-Problems ashx The Messages given on page 3 of this section are particularly relevant in this case: "As a general practitioner(GP)you should have an understanding of how common endocrine or metabolic disorders such as diabetes mellitus, thyroid or reproductive disorders can present: You must also be aware of rarer and important disorders such as Addison's disease, which can be potentially life-threatening if missed Biochemical tests can be diagnostic often necessary for monitoring metabolic and endocrine diseases.so it is important for GPs to know which tests are useful in a primary care setting how to interpret these tests and understand their limitations" "Lack of GP routine vital sign monitoring eg heart rate_blood pressure and weight measurement: Noestablished system for recognition_assessment and management of electrolyte abnormalities within the_GP Practice
5. Lack of understanding of the_underlying causes of hyponatraemia Guidance on the use of routine tests in general practice is provided on page 6 of the Section on "Primary Care Management" a GP you should_
1.6 Understand the use and main limitations of tests commonly used in primary care to investigate and monitor metabolic or endocrine disease, e.g: fasting blood glucose, HbAIc, urinalysis for glucose and protein, urine albumin: creatinine ratio, 'near patient testing (point of care testing)for capillary glucose, lipid profile and thyroid function tests, and uric acid tests" Insufficiently detailed referral letter to EDS Guidance on referral to secondary care is provided in the following sections. Being a GP http:LLwWW rcgp org_uklgp-training-and-exams [media/FilesIGP-training-and-exams[Curriculum 2012[RCGP-Curriculum-1-Being-a-GP ashx This section advises the general practitioner at all times to: "1.3 Co-ordinate care with other professionals in primary care and with other specialists" And spells this out as follows: This means that as a GP you should:
1.3.2 Understand the importance of excellent communication with patients and staff for effective teamwork
1.4.2 Understand the processes of referral into secondary care and other care pathways Royal College of General Practitioners 30 Euston Square London NW1 2FB Tel 020 3188 7400 Fax 020 3188 7401 Email info@rcgporg.uk Web WWw rcgp.org uk Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106 Key and and "As

1.4.3 Manage the interface between primary and secondary care, including unscheduled care, accurate sharing of information on medicines communication with other professionals
1.5 Make available to your patients the appropriate services within the healthcare system This means that as a GP you should:
1.5.2 Develop your organisational skills for record-keeping, information management; teamwork, running a practice and auditing the quality of care" (You will see that in this section, the need for excellent communication based on full, accurate records is again emphasised ) Guidance on the writing of referral letters is provided in the section The General Practice Consultation in Practice" http Iwww_gponline com/rcgp-curriculumlthe-general-practice-consultation hope you find these comments helpful.

Dear Dr Henderson Inquest into the death of Clare Cooper REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Further to the conclusion of the inquest into Miss Cooper's death on 11th 2014, you wrote to Surrey and Borders Partnership NHS Foundation Trust in accordance with the Regulation 28 report to prevent future deaths, stating that during the course of the inquest the evidence revealed matters giving rise to concer: We would like to take this opportunity to offer our sincere condolences to Miss Cooper's for their loss. The areas of concern you raised that relate to our Trust and our responses are detailed below: Lack of evidence of a robust assessment of presenting signs and symptoms with a presumption of psychologicallpsychiatric problem without considering or excluding an organic cause have revised our referral form in order to try and improve the quality of information that GPs provide when referring patients The fomm asks for more detail from the GP including that they consider and exclude organic causes of weight loss prior t0 making a referral to the Eating Disorders Service: The form also highlights the need for the GP to provide further details of the nature of the eating problem, results of blood investigations, physical examination and past medical history SO that all information is available prior to assessment by the Eating Disorders Service. It is hoped that as well as assisting the Service in prioritising the referral, identifying if a medical assessment is necessary and optimising the assessment process, the details required in the revised form will also act as a prompt for the GP to consider the possibility of organic disease in those presenting with eating difficulties. For abetter life Trust Headquarters, 18 Mole Business Park, Leatherhead, Surrey KT22 ZAD T_0300 55 55 222 F_01372 217111 wwsabp nhsuk July family We

Lack %f understanding of the undertying causes of hyponatremia (consistently or Intermittently low) and the level below which will require further investgatlon; and the investigations that should be caried out particularly in circumstances when thore is no obvlous cause of the low sodium_ We acknowledge the importance ofincreasing knowledge and awareness within the Eating Disorder Service about possible causes of hyponatremia and when t0 seek further investigations. We will be addressing this need through the Trust-wide eating disorders academic meeting during which there wll be teaching session for all clinical staff specifically about presenting symptoms and signs of Addisons disease including psychological manifestations, causes of hyponabemia and circumstancesllevels below which further investigation should actioned Insufficiently robust EDS profoma used to patients for an eating disorder: lack of prompts and a need to emphasize and exclude possible organic causes, however rare: The lack of a documented list of potential diagnoses t0 be assessed and excluded at including organic causes: need to facilitate communication from the referral agents to the eating disorder service: The triage assessment fom was introduced number of years ago as screening assessment t0 establish if the patient met the criteria for having an eating disorder that our service could help with, rather than being developed as comprehansive assessment form: This enables us t0 see people quickly and avoid waiting lists If the person is found to be suitable for our service, are then offered a fuller assessment We have however reviewed our triage fomm t0 ensure that all infommation including physical investigations is recorded in one form. The changes made include: Box t0 record blood investigation results 2 Box t0 record findings of physical examination 3
3.Box t0 record details of physical symptoms and past medical history with prompts: The form also has an addendum reminding staff t0 be alert to the possibility of organic causes of illness when assessing new referrals: It provides a list of examples of possible conditions that may present with weight lossleating problems: We are Of the vew that this revised fom will prompt our staff t0 make contact with the GP where required t0 request organic causes t0 be ruled out: it is our expectation that in cases where any symptoms are atypical, that would be discussed with the medical staffin the team and appropriate action would be taken_ Lackof_hospital notes_available_for _the_patholeglst undertaking_thepost mortem to facilitate a greater oppontunity for clinical_pathologicel conelation in deaths which @0 unascertained and higher level of_sugplclon to explore pme causes 0f unexpected deathespecialbyin theyoung We are somy that there was an issue with making notes avallable t0 the pathologist to facilitate a review to detemine any clinical _pathological correlation: We work really 2 triage triage, they they

closely with all interested parties to share clinical records including the Coroner and the pathologists: In this incident we shared records with the family (including the professional witness) and our Medical Records Team was in constant communication with them about access to records, but we are unable to find any information about any delays or issues with making these records available to the pathologist We have shared this concer with our Medical Records Team and we will continue to support them in ensuring that all records are made available in a timely manner to the pathologist in the future_ Our Board has been made aware of your letter and we would like to offer our sincere condolences again to the Cooper family for their loss. We that the steps we have taken as outlined above assure you and Miss Coopers family that we have leamt and continue to leam from Miss Cooper's death. Please do not hesitate to contact me or Director of Quality (DoN) if you require any further information_

Dear Dr Henderson, Re: Miss Clare Cooper (Regulation 28 Report Action prevent Future Deaths): Thank you for your letter dated 25.7.2014. have been aware of this case since the family approached me to the Coroner's hearing; seeking to instruct me in a expert capacity regarding their daughter' s tragic death: At that stage , indicated a conflict of interest, given my leadership of the Royal College of Psychiatrists Eating Disorder Section, but do therefore have a longitudinal knowledge of the case. have already responded to the family' s own correspondence with myself, and attach this for your interest: The issues raised in your report address the need for better EDS proformas in the triaging of patients with eating disorders On behalf of the Royal College of Psychiatrists, agree with this entirely. However would add two additional points. First; the Royal College of Psychiatrists is generally concerned about risk assessment in psychiatry, over ad above eating disorders, with undue reliance on risk assessment proformas_ This is reflected in the Alderdice and the Kennedy reports on suicide and homicide prevention, with services increasingly using risk assessment proformas as & type of 'checklist necessary but not sufficient in the evaluation of risk Proformas provide helpful aide memoire, but are insufficient to allow the detection of relatively rare differential diagnoses_ Thus, as well as decent proformas, we require eating disorder specialists with adequate medical training: As a Faculty, we assert the need for better standards of eating disorder specialism , and have submitted curriculum to the GMC for training standards to be met before doctor is recognised as a specialist in eating disorders_ istered office: 21 Prescot Street, London, El SBB Tel: +44 (0)20 7235 2351 +44 (0120 7977 6655 Fax: +44 (0120 3701 2761 WWw rcpsvch.acuk Charity registration number: 228636 NO HEALTH WITHOUT MENTAL HEALTH prior Regi

We also have concems over the heterogeneity of outpatient services across the UK have established standards for inpatient services (available at: http IIww rcpsych ac uklworkinpsychiatry/qualityimprovement aspx)_ but outpatient services are based on local commissioning decisions For example, we are aware of some outpatient services with limited medical input The specific issue of robust EDS proformas is best tackled through the MARSIPAN Guidelines of the Royal College of Physicians and the Royal College of Psychiatrists, which address physical risk monitoring in eating disorders: co-authored the original guideline, and have CO- authored a revised guideline , but the lead in this has been whose expertise in risk assessment in eating disorders is well recognised. As you will see in my correspondence with the family, will ask to consider how best to disseminate robust EDS proformas across the UK health economy, probably best tethered to the launch of the revised MARSIPAN Guidelines, which is forthcoming It would be within the remit of MARSIPAN to provide 'a national protocol for assessing patients seriously ill with an eating disorder with possibility_of_detecting individuals with an organic basis for the condition' also understand that has knowledge of this specific case. am likely to step down as Chair of the Royal College of Psychiatrists Eating Disorder Section before the end of the year, though attend the next Executive Committee Meeting in the autumn will raise the issues within your letter at that meeting; but wished to correspond prior to the next meeting,given the deadline for a response of 56 days Thereafter, the administrator of the committee at The Royal College of Psychiatrists, 21 Prescot Street, London E1 8BB. Kind regards, Consultant Psychiatrist will

Dear very 25th have history ~

All of the doctors at Woodlands Surgery have reflected on the matters of concern that you raise in your report;, please find outlined below the comments from the practice and steps that we have taken in respect to each point of your report which relates to the care covered by the practice
1. Poor GP documentation We have all agreed that all consultations should be fully documented in the patients' notes_ All patients should have a proper assessment of their history and a full examination should be done and routine vital signs should be recorded if they are clinically relevant: We have all agreed that the notes keeping in this case should have been better and may have compounded the issue relating to lack of continuity of care. In order to improve patient care and ensure that an episode like this is not repeated, doctors at the practice have agreed that as part of their ongoing personal development plan to submit anonymised consultation notes for their next appraisals. This will give a chance for each individual doctor's appraiser to assess the quality of note keeping: 2_ Lack of evidence of a robust assessment of presenting signs and symptoms with presumption of a psychologicallpsychiatric problem without considering or excluding an organic cause Upon reflection all of the doctors have agreed here at the practice that functional cause was accepted far too readily by the doctors involved in Miss Cooper's care and that an organic cause should have been considered and reconsidered upon subsequent consultations_ Miss Cooper's hyponatraemia was dismissed too readily and should been investigated further
3. Lack of GP routine vital sign monitoring
e.g: heart rate, blood pressure and weight measurement when weight loss is a concern with lost opportunity to assess the severity of weight loss We have all agreed that all patients should have a proper assessment of their history and a full examination should be done. Routine vital signs should be recorded if are clinically relevant If patient presents with weight loss then the weight loss needs to be objectively documented with serial weight measurements_
4. No established system for recognition, assessment and management of electrolyte abnormalities within the GP practice andlor consideration of the chemical pathology service to up' particularly concerning results The system at the practice at the time for identifying abnormal electrolyte results was that all results are seen by the patients" usual registered doctor. It is the responsibility of the patients' usual registered doctor to action and file the results. In relation to this case the results were seen and filed by Miss Cooper's registered doctor: Miss Cooper was reviewed here at the practice within week of each abnormal electrolyte result. The practice has considered what if any specific changes can be made to the in which we have they "flag way

handle abnormal pathology results as a result of this case_ Unfortunately we do not consider that there are any specific system changes that can be implemented but have highlighted to all clinicians the importance of monitoring and assessing electrolyte abnormalities and appropriate follow up.
5. Lack of understanding of the underlying causes of hyponatraemia (consistently or intermittently low) and the level below which will require further investigation, and the investigations that should be carried out; particularly in circumstances when there is no obvious cause of the low sodium We have all discussed at length the causes of hyponatraemia and the investigations required to make a diagnosis of Addison's disease_ am now sure now that all of the doctors here at the practice fuller understanding of this rare condition: In addition all of the GPs will now be completing the BMJ online learning e-module on hyponatraemia: We will add this iearning need to our PDP's and will be submitting this for our appraisals. We have also invited Consultant Endocrinologist at East Surrey Hospital to give lunchtime educational meeting here at the practice on hyponatraemia and Addison's Disease_ This is provisionally booked for Monday October 2014.
6. Insufficiently detailed referral letter to EDS (mentioning "Iow sodium" but not accompanied with copy of the blood results) and an opportunity was lost for its significance to be considered 99% of referrals from Woodlands . Surgery go to Surrey and Sussex Healthcare Trust (SASH): The Trust is linked in to the pathology software s0 for the vast majority of our referrals the hospital does have access to our patients' pathology results_ However from now on all patient referrals will have copies of all investigations (not just blood tests) attached with them to the referral letter:
9. Lack of hospital or GP notes available for the pathologist undertaking the post mortem to facilitate a greater opportunity for clinic-pathological correlation in deaths which are unascertained and a higher level of suspicion to explore rare causes of unexpected death, especially in the young GP notes are always available for post mortem examinations: do need however to be requested from us by the pathologist Unfortunately the practice did not receive request on this occasion. hope that this response has reassured you that the practice has taken this case and your report very seriously. If you need any further information please do not hesitate to contact me