Dear Ma'am Re Inquest touching upon the death of Zarah Ravn Regulation 28 Report Response We are writing to provide our response to your Regulation 28 Report dated 8 May 2024. We have read the report carefully set out below the action that has been taken, in particular the changes to our Severe Mental Illness (SMI) annual review processes and improvements to our Hormone Replacement Therapy (HRT) prescribing and review practices: Action Taken before the Inquest Ms Ravn'$ death was discussed as a significant event at a Practice Meeting on 28 November 2023. Ms Ravn had had regular physical and mental health reviews up to December 2019, which was the last time a physical, mental health and medication review are all recorded. From 2020 onwards, the reviews became more sporadic most likely due to the impact of the Covid-19 pandemic (chronic disease long-term condition reviews were suspended for GP Practices in 2020 in order to free-up time to manage the pandemic): Ms Ravn had a physical health review in February 2021 and January 2023 and her mental health was discussed at appointments in March 2021 and February 2022, but there were no formal mental health care plan medication reviews after December 2019. A number of actions/learning points were identified at the significant event discussion in November 2023, including: A need for a new/consistent process for tasking GPs to undertake mental health and medications reviews once physical health checks and blood tests have been completed for patients with an SMI: Reminders to clinicians to use templates for assessing patient with an SMI; which will prompt a holistic review and ensure review dates are created. need to remind clinicians to document risk assessments regarding the seriousness of suicidal intent and arrangements for follow-up Training for Healthcare Assistants on the annual physical health check for patients with an SMI: Armed Forces veteran friendly accredited GP practice WWW ashlea nhs_uk and diary

We noted during the discussion that since 2022, an IT Assistant had been employed to assist with long-term condition management reviews (and identifying when these were outstanding) and that this was assisting with identifying outstanding chronic disease reviews. We also noted that questions around changes to mood had been included in our updated HRT review protocols, that mood assessment was now routinely included as part of the HRT prescribing review. meaning The actions identified above were disseminated to staff and actioned in the months that followed. However, during the course of the Inquest on 20 February 2024,it became clear that these steps were insufficient to ensure that all aspects of the SMI annual review were being done concurrently and consistently: During the Inquest; it also became clear that there was no process in place for checking that improvements to HRT reviews were taking place: Action Taken after the Inquest Ms Ravn's case and the findings at the Inquest were reviewed again after the Inquest: We noted that whilst the improvement actions implemented following Ms Ravn's death were individually helpful, a more joined-up approach was needed to create a smooth and robust process for (all aspects of) the annual SMI reviews, and to ensure that changes to both SMI review and HRT prescribing practices and recommendations had been embedded. These further development actions were added to the agenda for a Practice Meeting on 13 March 2024, with the intention to then create new policies to (1) codify the updated annual SMI review and HRT prescribing review processes; (2) set clear expectations against which compliance can be audited; and (3) improve patient care delivery and experience in these areas New Severe Mental Illness Annual Reviews Policy We enclose a copy of the Practice's new Severe Mental Illness Annual Reviews Policy: This policy creates a process for making sure that patients with an SMI have annual physical, mental health and medication reviews The policy should be self-explanatory, but we have summarised below, with some additional comments about the rationale behind the changes made: Our IT Assistant runs searches of the SMI Register once a month to check for any patients who have not had physical health review in the past 12 months A list of relevant patients is then passed to the Healthcare Assistant who contacts the patient(s) to make appointments for the annual physical health review: During physical health review appointment, the HCA books the patient's Mental Health and Medication Review appointment with a GP; to take place within 2 weeks. This is a new step to ensure that all aspects of the annual SMI review are completed, and as simultaneously as possible (as opposed to the HCA (physical health check) and GP (mental health and medication reviews) being done at different times of the year; which had been happening before): The two-week gap between the physical health check and the mental health/medication reviews with the GP is however intentional, so that the GP can review/act on the blood results as necessary at the medication review: This would not be possible if the physical, mental health and physical health appointments were all booked for the same as the blood results would not be available. Once the GP has completed the mental health and medication review, record this with a coded in the notes ("Mental health annual review completed") and set a date for next review within 12 months_ The coded review date will show up in IT Assistant's searches the following year; to start the annual review process again: The diary review date also appears as an alert in the patient's record if/when it becomes overdue, as an additional safeguard. Staff are expected use Ardens templates for documenting physical, mental health and medication reviews This is new particularly for GPs, who did not always use templates once these became available within the Practice Ardens is a clinical decision and workflow support system that assists GP Practices with optimising patient care and recording data. produce clinical templates designed to standardise consultations for chronic disease management; which are updated regularly in line with the latest national guidelines. The use of Ardens templates Armed Forces veteran friendly accredited GP practice WWW ashlea nhs_uk any the day; they entry the entry They

for annual SMI reviews assists with structuring the review; ensuring that all the necessary checks and steps are taken, documenting the review and capturing relevant coding data to assist with monitoring: In relation to point 1 above, we are aware that the Coroner was concerned that this search process had failed in Ms Ravn' $ case because she did not have an annual review in 2022. However, it appears there was a delay rather than a failure to organise the review for Ms Ravn once the IT assistance was in place in 2022: it had taken time for the IT Assistant to undergo training and for staff to work through the backlog of patients requiring review (for all chronic conditions) after Covid. This meant that whilst additional IT support was in place to identify patients in need of reviews in 2022, not all patients had their annual chronic disease reviews in 2022. Ms Ravn had physical health check on 31 January 2023. There were no processes in place at that time to link the physical health check with other annual SMI review requirements, but that has now been addressed through 3 above Audit new Annual SMI review policy was approved on 30 March 2024 and has been disseminated to staff. Our IT Assistant has been carrying out monthly reviews to check that the searches she is is resulting in annual checks completed: Feedback so far indicates that the system is working well: patients are attending for their physical and mental health/medication reviews, and with a better attendance rate too because the patient is now getting the doctor' $ appointment booked by the HCA before they leave the physical health check appointment: Compliance with the new SMI review policy will be formally audited in September 2024 to check that it is working and that staff are complying with the requirements. It will be reaudited if necessary within 3-6 months and then added for review on an ongoing basis at the Practice' s annual compliance meeting: New HRT Prescribing We have also now introduced a written HRT Prescribing (as an appendix to our existing Prescribing Policy) to standardise our practices in this area and to ensure all women receiving HRT are reviewed regularly in line with current guidance. We enclose a copy of the HRT Prescribing Policy: Again, this policy should be self-explanatory, but we have highlighted some of the changes below: The policy confirms that there must be a review within 3 months following the first prescription of HRT. The use of the relevant Ardens Template is advised to assist with ensuring a comprehensive review process in line with the most up to date guidance Staff have been given training on setting up a standardised Accurx Questionnaire to trigger the first HRT review: Accurx is another workflow toolkit used in Primacy Care, which enables Practices to communicate with patients electronically, and it is utilised as below for HRT reviews: At the first appointment when HRT is prescribed, the GP prescribes no more than a 12-week supply of HRT medication and enters a date in the patient's notes for the HRT Accurx Questionnaire to be sent to the patient via text message within 12 weeks. Patients are advised to expect a questionnaire, and that we will use their responses to assess whether the HRT medication can be continued/any adjustments are required and/or if they need to be seen again. The questionnaire contains all relevant questions to ask when reviewing HRT; including changes in mood. We enclose a copy of the questions. patient has 7 days to respond to the questionnaire. Once received, the questionnaire response is reviewed by the GP and they decide future management as appropriate, including programming further reviews as necessary until the patient is settled on a stable dose. The policy confirms that once patient is established on a stable dose, there should be ongoing 12-monthly reviews as a minimum (to be completed by a GP or Pharmacist using the relevant Ardens template): Armed Forces veteran friendly accredited GP practice WWW ashleanhs_uk point The doing being Policy Policy key The will

(iv) Generally speaking, we have found that patients are at responding to the Accrux questionnaire and providing articulate/detailed answers. However; if for any reason a patient does not respond within days, the doctor receives a notification so the patient can be contacted again. The policy is clear that a second prescription for HRT should not be issued unless the patient has responded to the questionnaire or had a review: Audit Compliance with the new HRT prescribing policy will be audited in September 2024 with a review of all patients started on HRT medication since 1 April 2024, to check and ensure that (1) questionnaires are sent; (2) appropriate and timely reviews have taken place; and (3) templates and codes are being used for the HRT medication review process The need for further audit will be assessed again at that stage, and the policy will be included in our annual compliance meeting: Risk Assessment and follow-up for patients reporting thoughts of suicide When Ms Ravn's case was re-discussed at the Practice Meeting on 19 March 2024, we also took the opportunity to remind GPs that a risk assessment must be completed when any patient expresses thoughts of suicide, and to reiterate the importance of documenting the discussion and agreed action/follow-up arrangements We went through what questions to explore with the patient, what risk factors and protective features to consider and the options for referral/follow-up. GPs have again been encouraged to use the Ardens template for suicide risk assessment; which to ensure all relevant risk assessment factors are explored with the patient: We have also asked GPs to complete the suicide prevention training on TeamNet by 30 September 2024, by way of refresher training, and this will be monitored by our Practice Manager to ensure training has been completed. Conclusion We hope this letter demonstrates that the Practice has taken comprehensive action in response to the concerns identified during the course of the Inquest, and that compliance with the improvement actions will be monitored over the next six months (and beyond) to ensure changes to working practices are embedded and maintained_ Yours faithfulll For and on behalf of all Partners at Ashlea Medical Practice Armed Forces veteran friendly accredited GP practice WWWashlea nhsuk good has being helps