Dear Sir/Madam Re: Carly Marie Gordon D.O.B. 11/04/1980 Deceased D.O.D. 27/05/2016 Thank you for your regulation 28 report on Carly Gordon. note your concerns during the course ofthe inquest were twofold for our practice_
1) The long term use of shorter acting Benzodiazepine instead of longer acting Benzodiazepine in accordance with the British Association of Psychopharmacology (BAP) Guidelines should be followed when patients are prescribed this drug to avoid dependence: have read thoroughly both: a) BAP updated guidelines: Evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity (May 2012) b) Benzodiazepines: Risks and benefits. A reconsideration (Nov 2013) The points for Benzodiazepine dependence from Guideline (May 2012) are: "Where dependence is established, gradual dose reduction of prescribes Benzodiazepine is recommended" _ During my regular reviews of Carly this was discussed and carried out, It was made clear at the start of prescribing this should not be for term use, however as will discuss later, clinical indications meant the use of Lorazepam continued longer than either myself or the patient would have wanted at initiation. key long

Fremington Medical Centre FRFMINGTON 11/13 Beards Road Fremington Barnstaple Medical CENTRe EX31 2PG Tel: 01271 376655 Fax: 01271 321006 WWW . fremington org "Switching from a short half-life Benzodiazepine to a long half-life Benzodiazepine before gradual taper should be reserved for patients having problematic withdrawal symptoms' In this case at the time felt the clinical indication for Lorazepam outweighed the risks. did not swap for long active Benzodiazepine: have reflected on this decision and will change any future prescribing practice. "Additional psychological therapies increase the effectiveness of gradual dose reduction particularly in individuals with insomnia and panic disorder" asked Carly to call (which she did) the Depression and Anxiety Service twice and referred her to our local Psychiatric team: The points have taken and reflected upon from the BAP paper in 2013: "Whenever Benzodiazepines are prescribed, the potential for dependence or other harmful effects must be considered. The balance of risks and benefits with Benzodiazepines or alternative interventions in an individual patient can be hard to assess, and is ultimately a matter of clinical judgment" _ felt and recall in numerous review consultations that the benefits of prescribing in the first 6-12 months for Carly outweighed the risks In point 7 of the BAP commentary on page 971 it makes the point: 'Many health professionals have been dissatisfied with the previous guidance that Benzodiazepines should be used for short-term treatment only and no longer than four weeks in regular dosage: AIl patients should be made aware of the risks of dependence if they continue Benzodiazepines in regular dosage over longer period. (I recall discussing this with Carly}: A clinical judgment has to be made as to whether alterations may be more suitable for each patient, and for proposed medication' When it became obvious little progress was being made sought specialist consultant psychiatric advice_ Carly was told at that appointment to stop the Lorazepam_ We then embarked on a gradual reduction (although her perception at the consultant appointment was to stop it immediately) however she did not use the alternative antidepressant as suggested: Key

Fremington Medical Centre FRFMINGTOn 11/13 Beards Road Fremington Barnstaple MEdicaL CENTRE EX31 2PG Tel: 01271 376655 Fax: 01271 321006

"Benzodiazepines anxiolytics should be prescribed primarily either for the short-term relief of severe anxiety symptoms, or where anxiety disorders are disabling and severe and causing both significant personal distress and substantial impairment of daily activities" "Dependence is more likely with higher dosages but can also occur with lower doses and formulations of compounds at lower strengths and with longer half-lives may be useful in helping patients reduce from higher doses Even after short-term use, a tapering off regime, i.e , at least two weeks at reduced dosage, should be considered to minimize the risk of rebound phenomena, that is the reappearance of symptoms present prior to treatment" _ In regard to my own personal prescribing have audited every patient have prescribed Lorazepam to between 27/05/2016 and 13/09/2017_ There have been thirteen patients in total: have looked at all the notes: Of those thirteen; ten patients are not currently being prescribed Lorazepam: Those ten were either given one off scripts or very limited amounts (all less than two months): The remaining three have Lorazepam on repeat prescription_ have thus also audited every patient in the practice who has Lorazepam on repeat prescription; there are eighteen (including the three have prescribed for in the above time period) Of those eighteen, five patients live in term residential care for learning disabled and their medication is managed by consultant psychiatrist_ practice currently has twenty patients whom have either Zmg or Smg of a long-acting Benzodiazepine, Diazepam, on repeat: two of which live in the aforementioned residential home _ long-t The

Fremington Medical Centre FRFMINGTOn 11/13 Beards Road Fremington Barnstaple Medical CENTRE EX31 2PG Tel: 01271 376655 Fax: 01271 321006 WWW_ fremington org
2) AIl patients who receive this for an extended period of time should be reviewed by their medical advisors to reassess their suitability for the long term use of this particular medication Reviewing medication is practice at our surgery: However we have now considered a structured systemic approach for patients on Benzodiazepines to those reviews following our own significant event discussion of this case and the regulation 28 report For those patients who have a Benzodiazepine on repeat prescription, each have received a personal letter from their own General Practitioner asking them to contact us for targeted medication review of their Benzodiazepine_ We have made a commitment not to add (or continue repeat prescriptions from patients registering from other practices) Benzodiazepines to a repeat prescription if not already on repeat: For those thought requiring acute prescriptions we have reminded prescribing staff of the requirement to discuss with patients about the short term use of Benzodiazepines and regular reviews of both symptoms and prescriptions; also, not to add these medications to repeat prescriptions hope my own personal audit evidences that: Further action taken: have referred myself voluntarily to the Deputy Medical Director/RO Appraisal, Revalidation_Performance Lead NHS England Devon, Cornwall; Isles of Scilly Area Team; This is in order for her to review my performance in the management of Carly Gordon: have significantly reflected on this case and will discuss this with my appraiser. would like to say on a personal note how sorry am that could not help Carly more She and had an excellent rapport and for a long period of time she was really improving from her lifelong anxiety; she found job and was becoming more confident; was and still am deeply shocked by her death and my thoughts go out to her family.

Dear Mr Tomalin, Inquest into_the death of Carly Marie Gordon RCGP response Thank you for your letter seeking comments from the Royal College of General Practitioners on factors relating to general practitioner care following the inquest you conducted into the death of Carly Marie Gordon last was very sorry to hear that Ms Gordon had died On behalf of the College, set out below a brief description of the remit of the Royal College of General Practitioners_ also provide some detailed comment on the specific concerns you raise in your report with regard to the RCGP s expectations for general practitioner care in the case of a patient presenting with symptoms such as those of Ms Gordon: The ole 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 significant 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 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: (The curriculum forms the foundation for GP training assessment across the UK, prior to taking the College s Membership Examination (MRCGP) and is relevant to GPs throughout their career; including preparation for revalidation) httpllWW Icgp org uklgp-training-and-examslgp-curriculum- overview aspX 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 Ww.rcgp.org:uk Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106 year: set and

The Royal College of General Practitioners provides guidance to general practitioners on use of benzodiazepines and other medication. For your ease of reference, have attached the 2013 consensus statement which was developed with a range of partner organisations. In general terms benzodiazepines should be used in lowest possible dose ad for shortest possible time. Should patients find it difficult to withdraw even after 2-4 weeks, guidance is available for supporting safe withdrawal in support with psychological service and specialist services Where needed. RCGP curriculum currently contains safe prescribing and medicines management approaches and this is examined routinely as part of the Membership Examination which all doctors take should wish to be accredited as general practitioner, Details of the curriculum can be found at http IWWWICgp org ukltraining-examslgp-curriculum-verviewlonline-curticulum managing_complex care/3-14-drugs-and-alcohol-misuse aspx: can confirm that that this important work is included in the training of all GPs. to the learning are statements in the curriculum as follows: Appreciate that and alcohol use is common the community and that harmful use is often unrecognised and can take a range of forms (including excessive binges, risk-taking behaviours or dependency) Understand the presenting signs and symptoms of druglalcohol misuse, as well as the signs and symptoms of withdrawal) Make sure that repeat prescriptions are monitored for long-term prescribing of addictive drugs and appropriate action taken if this is happening: Work in partnership with the wider primary healthcare team including pharmacists, specialist services; the voluntary and criminal justice sectors In addition to my comments above, the RCGP supports a range of other educational initiatives which support the better prescribing of medication and thus the improved care of patients these include the RCGP certificate in the management of misuse and also a free to access e learning programme: Benzodiazepines and other psychotropic drugs can be effective when are prescribed appropriately and in accordance with clinical guidelines but the RCGP is very clear that there can be difficulties withdrawing them patient has been taking them for a period. Overall through our activities we would like to see a reduction in the number of prescriptions for benzodiazepines issued and via initiatives above this is our aim, trust that you will find these comments helpful.

Dear Mr Tomalin Re: Regulation 28 Report _ Carly Marie Gordon (died 25.05.2016) Thank you for your letter and Regulation 28 report dated 17th August 2017. am very sorry to of the tragic death of Ms Gordon and please extend my sympathy to her family: You raise two concerns:
1) The long term use of shorter acting benzodiazepine instead of longer acting benzodiazepine in accordance with the British Association of Psychopharmacology guidelines should be followed when patients are prescribed this to avoid dependence; and
2) All patients who receive this drug for an extended period of time should be reviewed by their medical advisors to assess their suitability for the long term use of this particular medication. In November 2013 the Psychopharmacology Special Interest Group of the Royal College of Psychiatrists and the British Association for Psychopharmacology (BAP) published a joint statement; with recommendations on the use of benzodiazepines in a paper entitled Benzodiazepines: Risks and benefits (Journal of Psychopharmacology 27(11) 967-971). In their paper the authors recognised the existence of widespread concerns about the use of benzodiazepines and related drugs. also stated that whenever benzodiazepines are prescribed, the potential for dependence or other harmful effects must be considered. They also recognised that; when prescribing these medicines, the risks of dependence associated with their long-term use should be balanced against the benefits of using short or intermittent courses of High quality care for all, now and for future generations 21TNHSL hear drug They

these agents, as well as the risks of the underlying conditions for which treatment is being provided. Whilst recognising the difficulties facing clinicians, the BAP guidance entitled Benzodiazepines: Risks and benefits supports an individualised approach to prescribing, based on clinical judgement; with the involvement of patients and carers (where appropriate) in the prescribing decision. Overall; the BAP guidance supports best practice as the short term or intermittent use of benzodiazepines, but also accepts that for a minority of patients longer term treatment may be appropriate; but in all cases vigilance of potential hazards is required throughout treatment: 'The balance of risks and benefits with benzodiazepines or alternative interventions in an individual patient can be hard to assess, and is ultimately a matter of clinical judgment: ' Advice on best practice in the management of benzodiazepine withdrawal is available through the National Institute of Health and Care Excellence (NICE) series of clinical knowledge summaries (CKS) available at bttps lIcks nice org uklbenzodiazepine-and-Z-drug-withdrawal#tlscenario: This topic covers the management of people who are prescribed long term benzodiazepine treatment and offers advice on the management of withdrawal of treatment It is important that prescribers and pharmacists are aware of the risks associated with the use of benzodiazepines when prescribing or dispensing these medicines_ In response to the specific concerns raised in your letter; will ask our National Clinical Director for mental health, and bur Head of Mental Health and LD Medicines Strategy to write to all medical directors and chief pharmacists in mental health trusts in England to;
1) Ask them to take a lead on raising prescribers' and pharmacists' awareness of the risks associated with benzodiazepine prescribing and withdrawal across their local health community;
2) Stress the importance of regular and close monitoring of patients who are withdrawing from benzodiazepines;
3) Highlight the risks associated with short acting benzodiazepines in particular;
4) Remind them of the statements and guidance published by the BAP and NICE clinical knowledge summaries; and
5) Raise the issues within their local area prescribing committees to ensure dissemination across both primary and secondary care prescribers. High quality care for all, now and for future generations

hope this provides you with the reassurance that NHS England is responding to your concerns and taking action to raise awareness of best practice guidance on benzodiazepine prescribing

Dear Mr Tomalin Re: Regulation 28 Report Reference: JGT SJ File No: 1307-2016 Thank vou for your letter dated 10th August 2017, apologise for the in responding: Devon LMC is dedicated to maintaining high standards of care and professionalism and is very happy to help disseminate important information in an appropriate manner to our members and constituent practices: can confirm the LMC, via our regular electronic newsletter, will remind practices regarding review of patients receiving short Benzodiazepines In addition, we will ensure the information is made available on our website. Please could ask you to provide a link to the relevant documentation? Once again, apologise for the and look forward to your reply Kind Regards Chair of Devon LMC Devon LMC To Lead, Represent, Inform and Support General Practice delay acting delay