Dear Dr Harris, write further to the regulation 28 report following the inquest death of Lisa Webb who concluded on the 7th April 2014 the sadly died on the 10th March 2012. considered the concerns set out at section 5 ofyour report and set - out my response below_ was saddened to learn about Ms Webb's death, had known that, she was her for several years as her GP, knew very good at managing her own symptoms of asthma which knowledge of how and when to use her inhalers: included a excellent anxiety in the was also aware that Ms Webb had suffered with past and had previously been on Citalopram, as recorded in October
2010. When Ms Webb came to me on 9th March 2012, as spoke to her and observed that she was breathing fast. This settled reassured her. took her blood pressure and pulse rate blood pressure twice an Omoron blood pressure monitor; took Ms Webb's during the consultation, recorded that it was 142/72 and this is normal: The blood pressure monitor showed Ms Webbs pulse record of the pulse rate rate was normal, regret that did not make a at the time. Action: Since Ms Webb's death make sure that during significant problems and reviews, checks consultations check the past of there are reviews done and review previous consultations also check to see if any outstanding and either complete them myself or ask the patiert appointment at reception for a review. also to make an record this advice within the patient's electronic record, understand that comprehensive medical records are improved my record keeping essential for good patient care and have and make more detailed notes. Surgery Abbey into have see using history

On the 9th March 2012, prescribed Ms Webb Diazepam: She came into the consultation and specifically asked for Diazepam. She explained that she thought it would her anxiety, which agreed and prescribed it for this reason. understand that a dose of between 2- 5 mg is a relatively low dose and initially thought that a dose of 2mg, twice per would be sufficient: Ms Webb indicated that she would rather use % a tablet of Diazepam: twice a which indicated to by the way she was explaining how she would use the medication dosage that she had used it before: was also conscious of the fact that Ms Webb had large body habitus and felt that this slightly higher dose would be appropriate in the total she was prescribed a 1 week supply. circumstances. In At the time did not know that Ms Webb had sleep Apnoea. She had never indicated symptoms to suggest that she had this condition and the symptoms she described on the were not contraindicated with Diazepam. ACTION: Since this incident explore more all patients' medical histories. that It Is important as a GP to ask the patient at the been reminded consultation to consider thelr past conditions which could be relevant to thelr current symptoms It is important to combine this with my own knowledge of their medical and the medical notes. Practice Meeting: Apractice meeting took place on 16" May 2014 with all clinical staff and the discussed. Coroners regulation 28 was We looked at whether any were needed implemented or whether and changes had already been in terms of managing asthma patients: also wanted to specifically consider Ms Webb's asthma not been aware that she had management: We discussed the fact that had not had an asthma review or peak flow done in 2 years confirmed that even though it was the patients anxiety which breathing difficulties it would was on that occasion causing her have been preferable to have check her peak flow and oxygen saturations; Ideally should also have reminded her to make an appointment foran asthma advice. review and recorded this We discussed the importance of monitoring asthma repeat inhalers. As regularly, particularly where a patient is receiving practice we agreed that regular checks need to be carried circumstances where a patient is very competent in out even in managing their own asthma, as was Ms Webb_ It was agreed that a reminder needed to be issued to all staff about patients who had outstanding not issuing repeat prescriptions to reviews: It was also agreed that reception staff need to be able to offer patients an emergency review s0 that medication/inhalers can be issued, The prescription of Diazepam was also discussed at the meeting: help day Smg day me, any day fully have changes

explained the circumstances of Ms Webbs attendance on the 12m March 2012 &nd described that she had anxious ad that she had specifically asked for Diazepam: explained that she had indicated some knowledge of this medication and its and felt it would help her anxiety: symptoms of As had known Ms Webb for several years and knew that she Was good at partner s managing her own and her medical conditions, felt that a prescription of Diazepam would be that following Ms Webb's death it transpired that she had sleep appropriate_ explained have issued this medication if | had Apnoea. explained that would not known this. In light of this incident we discussed, and reminded my colleagues, of the importance of asking questions about a patients and other symptoms even in circumstances have good knowledge of the where we feel that we patient: stressed that this is particularly important when we are prescribing medication. The importance of good quality record keeping was also discussed by me ad the meeting on the 16th 14, Practice Manager at AIl clinicalistaff agreed that comprehensive notes need to be made reminded t0 check whether and reviews completed. Staff were reviews had been completed and to discuss overdue reviews with patients_ It was agreed that in the event reviews cannot be should be asked to book completed during the consultation then patients a review with the appropriate clinician before they leave. We also this should be recorded within the patients' agreed that electronic record, ACTIONED: A reminder memo has now been provided by the Practice change of medications, reminders for Manager that ALL consultations, staft: overdue review invites must be completed on the screen by all Conclusion Since the death of Ms Webb and the subsequent inquest; up to date and that their now ensure that check patient reviews are each term conditions are being appropriately managed, make sure that at consultation review their medication and request tests where appropriate: It reinforced that good quality care includes following emphasised the correct guidelines_ This incident has also importance of keeping up to date with guidelines and to explore medical symptoms and history, to conduct with patients their thorough examinations and check for all possible diagnoses; It [s also important to make good quallty comprehensive have always made written notes in the patients' record. Although 'good records in the electronic notes am now more given to me by the patient in the consultation; vigilant in recording information comprehensive: this ensures that the records are more detailed and feeling dosage history the May long has

shall continue to keep abreast of the latest guidelines and to maintain and improve my knowledge by continuing my CPD. have undertaken a number of courses in order to consolidate, update and improve my knowledge in the following areas: 1, Chronic Obstructive Pulmonary Disease in Primary care 20/5/12 Course provider Doctors net:uk - CPD =1.5 My reflections and learning points for Chronic Obstructive Pulmonary Disease were: learned about the relationship of COPD with FEV and the use of FEV measurements regularly: 2 Shortness of breath Various aspects of difficulty in breathing 9/9/12 Course provider Doctors net:uk CPD
3.00 My reflections and learning points for Shortness of breath were: The ways of evaluating shortness of breath and the various aspects of difficulty with breathing:
3. Paediatric airway problems 4/8/13 Course provider Doctors net.uk CPD = 1.5 have strengthened my awareness ad ability to diagnose croup ad instituting treatment; Also remembering to Review the children with severe croup regularly: was also updated on the need for IV antibiotics in acute tracheitis_ In this Module of learning was reminded of the importance of having an emergency injection of Adrenalin available at all times to deal with anaphylaxis. It also reminded me to suspect a foreign body with an acute onset of respiratory distress and to also suspect foreign body inhalation if a child with no history of asthma who suddenly becomes distressed with breathing: If this is the case then should immediately give 5 back blows followed by 5 chest blows and then if no response to start resuscitation. was also reminded of the importance of keeping Oxygen ready when dealing with any paediatric emergencles with respiratory distress because of Hypoxia and to admit a child with tracheitis for IV antibiotics and possible resuscitation. Bronchfolitis Diagnosis & Management 16/12/13 Course provider Doctors net,uk CPD
1.5 My reflections and learning points for Bronchiolitis were: The assessment of children with breathlessness should include hydration, Oxygen saturations, feeding pattern: Respiratory rate CRT, the

This module also reminded me of the need to avoid routine antibiotics or steroids that are often given by doctors and to remember the emphasis on supportive treatment watchful of by explaining to the parent/s to be respiratory distress was also updated on the need to admit a child with Bronchiolitis which is more prevalent in the winter months 1 was also reminded that the initial presentation can be for would lead me to check hydration, coryza and poor which Oxygen saturation, CRT and to other diagnosis such as asthma pneumonia aspiration FB in an acute child and if the the respiratory oxygen saturation to under 92% and rate is over 60 then oxygen is needed and admission to hospital was also reminded to check FH for asthma and smoking status
5. Shortness of breath ~ 9/1/14- Course provider Doctors netuk CPD =1.5 My reflections and learning points for Shortness of breath were: The differential diagnosis of acute breathlessness in adults such as Asthma, obstructive pulmonary disease Pneumonia, Chronic also have an improved knowledge of how to assess acute dyspnoea together with an updated awareness of the Initial management of acute dyspnoea with checking = oxygen levels and appearance Also an improved awareness of latest guidelines which include checking saturation. capillary refill time and oxygen was also reminded of 'checking with parents on inhaler usage for children ad that indulging with the usage. are not over Was updated on a reduced respiratory rate may be due to opiates and a normal PCO2 below 92% is worrying sign in severe asthma and admission and Oxygen level maybe needed_ Difficulty in breathing has other causes and Chest X ray and antibiotics are and to always Monitor usually not needed routinely Oxygen in acute cases: The need for referring to secondary care in acute asthma with Oxyger levels of less than 92%. Was updated on recognising that Difficulty in breathing in malignant chest conditions other causes effusion: can be due to
6. Paediatric problems 22/1/14 course provider Doctors netuk CPD = 1,00 My reflectioris and points for Paediatric problems were: The need to assess a child with respiratory distress and if the needs oxygen saturation is <92% then child oxygen and emergency referral Other learning points were not to disturb child who is drooling and epiglottis but seek not to examine a child with urgent CPR: Also to avoid a nebuliser in child under 3 months of age as not any feeding keep wheezy drops atopy, they like breathing learning breathing the using

confirmed how the child would react and to seek immediate CPR in child and Oxygen levels < 92%. with silent chest cyanosis was also reminded of the importance of using the oximeter problems and to regularly in any child with respiratory assess on the basis of information obtained. Also to use concentration is <92%. oxygen where the oxygen To avoid antibiotics in viral respiratory infection.
7. Obstructive Apnoea 6/2/14 Course provider Doctors net .uk CPD - 1.5 My Reflections and learning points of Obstructive sleep Apnoea was: Obstructive sleep apnoea syndrome [OSAS] is the commonest treatable sleepiness _ cause of excessive awake time A patient with OSAS can present with in voice hoarseness, and dysphagia. character, severe nasal obstruction, unexplained was updated on importance of an increased sleep awareness of the risk factors for Obstructive apnoea such as obesity: Be familiar with the clinical presentation of OSA and know the OSA together with developed appropriate investigations for suspected OSA ie: how to understanding of the management options available for peopleecteh adapt their sleeping positions, avoid alcohol and sedatives; also learned to appreciate the negative outcomes associated with OSA. To investigate daytime sleepiness by checking CO levels and if any Anaemia, Detail clinical exam in OSA to include nasal obstruction, referral on suspicion of these hoarseness of voice dysphagia and earlier conditions, My total CPD hours (Including the above) were for 2012 = 57.252013
68.5 ACTION: shall continue to complete CPD courses and modules medical conditions that on all aspects of patient's diseases and study and complete on Doctors netuk which Is a interactive programme of courses. online hope that this response is of assistance, please do not hesitate assistance. to contact me if can be of further Yours sincerelv sleep change the having any