David Stables
PFD Report
All Responded
Ref: 2024-0676
Community health care and emergency services related deaths
Mental Health related deaths
Suicide (from 2015)
All 1 response received
· Deadline: 31 Jan 2025
Coroner's Concerns (AI summary)
There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns about whether these essential reviews were conducted or adequately documented.
View full coroner's concerns
(1) I am concerned that there were no recorded mental health or medication reviews from April 2020 until February 2024 when David attended the GP asking for help. I was unable to establish whether these reviews had taken place and just not been recorded or whether full mental health reviews had not taken place when they should have been. (2) (3)
Responses
Action Taken
The practice created a new mental health template to standardize the procedure and coding in clinical records for mental health reviews and medication reviews, and reviewed patients taking SSRI medications. They have updated the process for future patients discharged from mental health services, and patients on medication receive annual/biannual medication reviews. (AI summary)
The practice created a new mental health template to standardize the procedure and coding in clinical records for mental health reviews and medication reviews, and reviewed patients taking SSRI medications. They have updated the process for future patients discharged from mental health services, and patients on medication receive annual/biannual medication reviews. (AI summary)
View full response
Dear Ms Whittle
Re: Ref: 2024-0676 - David Stables
I am writing on behalf of the Dearne Valley Group Practice in response to the Regulation 28 Report dated 6 December 2024.
We recognise the concerns you have raised about the lack of recording of mental health review and medication reviews. I have been assured that reviews had taken place, but they were not clearly or accurately recorded by the clinicians who consulted with Mr Stables. I am writing to set out the steps we have taken to assure that we will record this correctly going forward.
1. On December 18, 2024, we held a clinical meeting specifically to address the concern raised in the Regulation 28 Report. As a practice, we agreed a process which will assist current and future clinicians to correctly code into the clinical record when they have completed a mental health review and/ or a mental health medication review. To do this we have created a new mental health template to standardise the procedure which all clinicians now use.
2. We have reviewed each patient who is currently taking a selective serotonin reuptake inhibitors (SSRI) medication using the new template, starting with patients who have been discharged from a mental health service, as was Mr Stables. All patients have received a mental health review and a mental health medication review, who have been discharged from a mental health service.
3. We have updated the process for future patients following discharge from any mental health service. Now, when we receive notification that a patient has been discharged from any mental health service, we will contact the patient to book them an appointment for an initial mental health review. If the patient has been prescribed an SSRI, we will review the patient between 1 to 4 weeks (as determined by the reviewing clinician and with the patient’s agreement) and ongoing until they are stable. Once a patient is stable, they will be recalled for review every 6 months whilst they are being prescribed SSRI medication.
4. Patients starting an SSRI for the first time will also be seen every 1 to 4 weeks until they are stable, after which they will also be reviewed every 6 months whilst they are taking the medication. If patients choose to stop the medication themselves without our knowledge, this will be picked up at the review date and a mental health review and discussed with the patient. We are using scheduled tasks for
The Thurnscoe Centre, Holly Bush Drive, Thurnscoe, Rotherham S63 0LT Tel:
The Goldthorpe Centre, Goldthorpe Green, Goldthorpe, Rotherham S63 0EH Tel:
Dearne Valley Group Practice & Partners
reminders to prompt clinicians to review the patients so that the responsibility is with the clinician and not the patient.
5. At our clinical meeting in December 2024 to discuss the recording of mental health reviews and mental health medication reviews, the clinical team were clear that reviews had happened in Mr Stables record, but the coding was missing. The coding requires a tick to be entered in a box which had not been completed. The new template which we created adds the code into the record when the clinician documents the history and examination of a patient when they are doing a metal health review, and there is a very clear prompt to confirm a mental health medication review has also taken place as well as set a scheduled task for the next review date. It has been made very clear to all the clinical team that in addition to undertaking reviews it is necessary that coding and clear wording of ‘mental health review’/ ‘medication review’ is included in order for clarity in the patient record so that it is clear to third parties that these have taken place, not just for mental health patients, but for all patients.
6. Patients who are still under the care of a secondary care mental health team will be reviewed by them, we will take over their care and treatment plan when the patient is discharged back to us.
7. Patients who we are currently prescribing medication for (all medication) will receive a medication review annually or biannually, and patients who are started on a new medication will also be monitored until stable at an interval in line with relevant guidance depending on their medication and then reviewed annually or biannually.
We hope that this will reassure you that we have taken your concerns on board and taken steps to review our processes and implement change.
Re: Ref: 2024-0676 - David Stables
I am writing on behalf of the Dearne Valley Group Practice in response to the Regulation 28 Report dated 6 December 2024.
We recognise the concerns you have raised about the lack of recording of mental health review and medication reviews. I have been assured that reviews had taken place, but they were not clearly or accurately recorded by the clinicians who consulted with Mr Stables. I am writing to set out the steps we have taken to assure that we will record this correctly going forward.
1. On December 18, 2024, we held a clinical meeting specifically to address the concern raised in the Regulation 28 Report. As a practice, we agreed a process which will assist current and future clinicians to correctly code into the clinical record when they have completed a mental health review and/ or a mental health medication review. To do this we have created a new mental health template to standardise the procedure which all clinicians now use.
2. We have reviewed each patient who is currently taking a selective serotonin reuptake inhibitors (SSRI) medication using the new template, starting with patients who have been discharged from a mental health service, as was Mr Stables. All patients have received a mental health review and a mental health medication review, who have been discharged from a mental health service.
3. We have updated the process for future patients following discharge from any mental health service. Now, when we receive notification that a patient has been discharged from any mental health service, we will contact the patient to book them an appointment for an initial mental health review. If the patient has been prescribed an SSRI, we will review the patient between 1 to 4 weeks (as determined by the reviewing clinician and with the patient’s agreement) and ongoing until they are stable. Once a patient is stable, they will be recalled for review every 6 months whilst they are being prescribed SSRI medication.
4. Patients starting an SSRI for the first time will also be seen every 1 to 4 weeks until they are stable, after which they will also be reviewed every 6 months whilst they are taking the medication. If patients choose to stop the medication themselves without our knowledge, this will be picked up at the review date and a mental health review and discussed with the patient. We are using scheduled tasks for
The Thurnscoe Centre, Holly Bush Drive, Thurnscoe, Rotherham S63 0LT Tel:
The Goldthorpe Centre, Goldthorpe Green, Goldthorpe, Rotherham S63 0EH Tel:
Dearne Valley Group Practice & Partners
reminders to prompt clinicians to review the patients so that the responsibility is with the clinician and not the patient.
5. At our clinical meeting in December 2024 to discuss the recording of mental health reviews and mental health medication reviews, the clinical team were clear that reviews had happened in Mr Stables record, but the coding was missing. The coding requires a tick to be entered in a box which had not been completed. The new template which we created adds the code into the record when the clinician documents the history and examination of a patient when they are doing a metal health review, and there is a very clear prompt to confirm a mental health medication review has also taken place as well as set a scheduled task for the next review date. It has been made very clear to all the clinical team that in addition to undertaking reviews it is necessary that coding and clear wording of ‘mental health review’/ ‘medication review’ is included in order for clarity in the patient record so that it is clear to third parties that these have taken place, not just for mental health patients, but for all patients.
6. Patients who are still under the care of a secondary care mental health team will be reviewed by them, we will take over their care and treatment plan when the patient is discharged back to us.
7. Patients who we are currently prescribing medication for (all medication) will receive a medication review annually or biannually, and patients who are started on a new medication will also be monitored until stable at an interval in line with relevant guidance depending on their medication and then reviewed annually or biannually.
We hope that this will reassure you that we have taken your concerns on board and taken steps to review our processes and implement change.
Sent To
- Dearne Valley Group Practice
Response Status
Linked responses
1 of 1
56-Day Deadline
31 Jan 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 28 March 2024 I commenced an investigation into the death of David Stables. The investigation concluded at the end of the inquest on 4 December 2024. The conclusion of the inquest was Suicide 1a Bilateral transection of the ulnar arteries 1b Incised wounds to the wrists
Circumstances of the Death
David Stables had a history of mental health issues and had taken two drug overdoses in 2020. He was prescribed sertraline in April 2020 and weaned himself off this in 2023. His last prescription was issued in July 2023. David attended many appointments at his GP practice from 2020 to 2023 regarding other issues unrelated to his mental health. In most of these encounters there is no record of any discussions regarding his mental health. Whilst he received repeat prescriptions for his sertraline, there is no recorded entry of a review of his mental health or appropriateness of the medication. It is noted that he had reduced this himself yet there is no recorded entry of a full review of his mental health at this time. I am concerned that there were no recorded mental health or medication reviews from April 2020 until February 2024 when David attended the GP asking for help. I was unable to establish whether these reviews had taken place and just not been recorded or whether full mental health reviews had not taken place when they should have been. In February 2024 he attended the GP surgery and had a face to face appointment regarding his mental health. He had anxiety and had difficulties in sleeping and poor appetite. A shared decision was undertaken to put David on mirtazapine at 15mg and to follow up in 4 weeks time. I was informed that this was considered because of its side effects of sedation and increased appetite. A full mental state examination was undertaken which did not identify any Self harm or suicidal concerns. On 18 March 2024 he was seen again by the GP and there was some improvement. I was told that self harm and suicidal ideation were specifically discussed and they were strongly denied at both appointments. There was no concern from the GP when he called 2 days later to ask to increase his medication although it was accepted that had she known he had tried to contact the GP surgery on 5th 14 and 15th March then this may have changed her management in terms of obtaining more information either by reception or by another appointment. However, I do find that whilst he may have attempted to contact the GP it cannot be ascertained if these calls actually made it through to the reception team. I find that there is no evidence to say that this would have changed the management in terms of the medication although it may have been considered. Further there is evidence that even if medication had been increased it could have taken up to 4 - 6 weeks to show any benefit. David had been given all relevant safety netting advice for a crisis and this was provided verbally and by text message.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.