George Cheese
PFD Report
All Responded
Ref: 2017-0179
All 1 response received
· Deadline: 29 Sep 2017
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
29 Sep 2017
All responses received
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
(1) While the evidence at the Inquest dealt with the various matters ongoing in Mr Cheese’s life, I also heard evidence of the care and treatment that he received from his GP surgery. One of the doctors at the surgery, gave live evidence at the Inquest.
(2) Mr Cheese was prescribed Fluoxetine anti-depressant medication on the 3rd November 2014 by a treating GP, following admitting to fleeting suicidal thoughts. He was reviewed by on 14th January 2015 when Mr Cheese described daily episodes of intense low mood with suicidal thoughts which included taking an overdose. This led to a reference to the Mental Health Team. At an appointment with the Practice’s Nurse Practitioner on 3rd February, Mr Cheese was prescribed 112 tablets of Fluoxetine. In the course of her evidence, stated that the Nurse Practitioner was probably just repeating the same prescription that the previous Doctor had issued to Mr Cheese but that she, , would not have done that.
(3) also acknowledged, in the course of her evidence, that there was no “flag” on Mr Cheese’s notes to alert treating Clinicians within the GP Practise to limit the amount of medication provided to Mr Cheese in view of his history. She acknowledged that a flag, in such circumstances, was good practise.
(4) The concerns arising from the evidence are therefore the amount of medication prescribed to a patient who was known to be suffering from mental health issues and describing suicidal thoughts and a potential overdose and the fact that this was not being flagged to prevent large amounts of medication being provided to him as a matter of repeat prescription.
(2) Mr Cheese was prescribed Fluoxetine anti-depressant medication on the 3rd November 2014 by a treating GP, following admitting to fleeting suicidal thoughts. He was reviewed by on 14th January 2015 when Mr Cheese described daily episodes of intense low mood with suicidal thoughts which included taking an overdose. This led to a reference to the Mental Health Team. At an appointment with the Practice’s Nurse Practitioner on 3rd February, Mr Cheese was prescribed 112 tablets of Fluoxetine. In the course of her evidence, stated that the Nurse Practitioner was probably just repeating the same prescription that the previous Doctor had issued to Mr Cheese but that she, , would not have done that.
(3) also acknowledged, in the course of her evidence, that there was no “flag” on Mr Cheese’s notes to alert treating Clinicians within the GP Practise to limit the amount of medication provided to Mr Cheese in view of his history. She acknowledged that a flag, in such circumstances, was good practise.
(4) The concerns arising from the evidence are therefore the amount of medication prescribed to a patient who was known to be suffering from mental health issues and describing suicidal thoughts and a potential overdose and the fact that this was not being flagged to prevent large amounts of medication being provided to him as a matter of repeat prescription.
Responses
Response received
View full response
Dear Mr Bedford, Thank Vou for your letter and report dated 6"h June requesting the surgerv' s response to the inquest of George Cheese about the number of your concerns raised at antidepressant tablets prescribed to him without adequate review. enclose a copy of our antidepressant prescribing policy; the result of discussions with partners which / hope will answer those concerns. my Shortly after George died the partners introduced the requirement for the issue of repeat prescriptions and depression reviews to be conducted by GPs only; receptionists are aware that patients with anxiety and depression cannot be seen by nurse practitioners This policy has been circulated to all our GPs and nurses/nurse practitioners. The addition of a or 'major alert' on the front screen of patient's record is the responsibility of the GP who initially assesses or reviews the patient should have concerns at time. This could include receiving a letter Talking Therapies expressing concern about aapettemcesucidalth thoughts_ have written up the role of the clinicians including the issue of 112 capsules of fluoxetine to George = on 2 occasions a5 a 'significant event' and will be discussing this at our next clinical meeting on Thursday 276 Analvsis of significant events is a requirement of the CQC (Care Quality Commission) inspection to July: that events that have been detrimental to patient care have been identified, discussed and demonstrate learnt with the aim of improving the quality of care: We have also arranged for lessons have been a consultant psychiatrist from the focal mental health team to talk about management of mental health disorders at our clinical meeting scheduled for Wednesday 23rd August. hope that these policy changes together with discussion and education will reduce the risk of overdose to patient in future. any
Action Should Be Taken
In my opinion urgent action should be taken to prevent future deaths in such circumstances and I believe your Surgery has the power to take such action.
Classification: OFFICIAL-SENSITIVE
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Classification: OFFICIAL-SENSITIVE
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Classification: OFFICIAL-SENSITIVE
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Classification: OFFICIAL-SENSITIVE
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Report Sections
Investigation and Inquest
I conducted an Inquest into the death of Mr George Arthur Cheese that was heard at Reading Town Hall between the 23rd and 25th May 2017 inclusive. The conclusion of the Inquest was that Mr Cheese took his own life whilst suffering from a depressive disorder brought on by a series of life events. A full copy of the Narrative Conclusion is attached.
Circumstances of the Death
Mr Cheese was an 18 year old young man who was found hanging in Woodland near his home address on 9th April 2015. He had a number of ongoing issues in his life including the potential loss of a career in the army; a fluctuating relationship with his girlfriend; an unsubstantiated concern that he might have a serious illness and he had been subject to upsetting treatment by his colleagues at work. He was under the care of his GP surgery and the local Mental Health Team who were treating him for anxiety and depression including prescribing anti-depressant medication.
Classification: OFFICIAL-SENSITIVE
-1-
Classification: OFFICIAL-SENSITIVE
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Classification: OFFICIAL-SENSITIVE
-1-
Classification: OFFICIAL-SENSITIVE
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Copies Sent To
of Mr Cheese
6th June 2017
Peter J. Bedford Senior Coroner for Berkshire
Classification: OFFICIAL
SENSITIVE
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.