Dear Mr Mrs Judith Anne Savlle deb 18091943id.0d 2804.2014 Further to my previous reply to you; we have now discussed Mrs Saville's sad death and the issues that you raised. I shall address the two points you raised with me individually. Firstly, although in an ideal world Zopiclone would only be used in short courses, it is common for this to be disregarded by patients, and where it seems the only way of relieving their distress at unable to we do sometimes have to use it on basis. Unfortunately; it is not unusual for people to take daily even though we normally try to persuade them to reduce o this medication where possible: However; sometimes continuing the medication regularly is the lesser of two evils_ In the situation in which normally we prescribe Zopiclone, short courses of limited numbers of pills are advisable and our" computer system automatically offers uS this choice with a label which advises against repeat or regular use. There will inevitably be some patients for whom it has been decided that regular prescription of one months supply is appropriate. In Mrs Saville' $ particular circumstance we would not necessarily agree that_ prescribed too many zopiclone pills, although we sympathise with his comments Viewing her prescribing records it appears that she was not prescribed on any single occasion more than a months supply at the doset hhad decided on We would certainly all agree that in cases where there is heightened risk of suicide we would endeavour to restrict supplies of potentially toxic medication of any type. Our local pharmacists ad dispensers do also to uS when patients appear to be requesting medications earlier than would be expected, As you will understand however; restricting prescribed medications would not prevent patients who have chosen to "stockpile" regular medications from holding numbers of any pill which we prescribe regularly. There are many medications which are much more toxic than zopiclone and of course many over the counter medications which would also be toxic in overdose Dr P J.R Taylor Dr J.G Halford Dr J.M Allen Dr S.A Ellis Dr BN McKenna Dr S.J Mount Dr E.P Guinness Dr LC Crosby Dr J Ashby GP Assistants: Dr Y.MB Hodges Dr Bates Dr A Beazley Cox; being sleep regular 1Smgs stop flag large C.E

Axminster Medical Practice 06 February 2015 Your recommendations have lead us to consider the methods available to GPs in assessing whether a patient might have an increased risk of suicide. Mrs Saville's medical records record clearly in the summary that she had taken two overdoses, one in 1994 after what is described as a marriage break-up and another in 2010. All the GP's agreed that it would be a normal part of assessing a patient to look at the summary page which is clear and easily accessible. All the information contained therein would normally be taken into account especially if it is relevant to the reason a patient is consulting: To have a special which highlights that a patient has taken overdoses in the past would be problematic because this is not relevant information for many such people and significant numbers of patient have taken overdoses in the past but are not at increased risk of repeating any form of self-harm. Patients rightly expect that their medical records are both accurate and do not stress information which might in some way be viewed as judgemental and a special or message which is given more weight than any other part of their medical history might well be offensive to some In Mrs Saville's case it is important to consider what action might have resulted if there had been a flag which suggested an increased risk of suicide. All the GP' $ present agreed that this might have prompted urgent referral to the Crisis Response Team for an assessment including the current suicide risk. The Crisis Team always guide uS if believe that a heightened risk should temporarily (or permanently) change our patterns of prescribing: understand that this referral was made and Mrs Saville was seen _ I believe that the wider GP community as a whole is likely to hold similar views and if you wish this could be raised with the Local Medical Committee who could advise uS accordingly. hope that you will find this reply satisfactory and shows that we have given your recommendations careful consideration The very fact of this will mean that the risk of suicide remains an important factor in assessing anyone with psychological problems If raising this with us makes difference to just one patient in the future then it will have been worthwhile.

Dear Mr Cox Re: Judith Anne Saville Regulation 28 Report to Prevent Future Deaths Thank you for your letter of the 15th January 2015 which we received on the 20th January 2015 following the inquest into the death of Judith Anne Saville As an organisation we are committed to learning from these tragic events and have since receiving your report and recommendations taken the opportunity to share your findings with the service involved as well as across the wider trust: As you noted at inquest the Trust undertook a Root Cause Analysis Investigation following the death, the Root Cause Analysis report contained a number of recommendations; all of which were accepted and the actions have now been completed_ have attached summary which details the actions identified in the original RCA and the progress made against each of these actions_ Whilst we have been able to complete the actions that were identified in the original Root Cause Analysis, the assurance that changes have been fully embedded into clinical practice is monitored through routine audit and this represents part of our continuing programme of quality improvement: As such we would expect to see on-going improvement over the coming months. Additionally every RCA action and evidence to support their closure is reviewed by our commissioner before the action plan can be formally closed hope that the actions described demonstrate our commitment to the learning we have undertaken. If you require any further information please do not hesitate to contact me_