Dear Regulation 28 Notification, Mr Darren Lee Arnoup Thank you for your recent correspondence and a request for a response from Mundesley Medical Centre regarding a Regulation 28 Notification: welcome the opportunity to review primary care procedures that may benefit patient care_ We recognise that your primary .concern was that 2 letters from the Colman Centre, Colman Hospital, Specialist Rehabilitative Services (dated 21.05.13 and
12.08.13) highlighting a suicide risk were not read by a GP. We have reviewed the course of events in detail, On
25.09.12 Alison Woods (Clinical psychologist Colman Centre For Specialist Rehabilitative Services) left a message for informing him that Mr Arnoup had attempted suicide the previous day. Apparently he had prepared a piece of rope but had stated that he did not want to commit suicide but wanted people to know how desperate he was. In response, arranged and conducted a telephone appointment with Mr Arnoup on 29.09.12 and recorded that Mr Arnoup was less tense about his employment problems. The Colman Centre also wrote to Mundesley Medical Centre on 2 occasions Contd overl._ nc@cimofd '2014 JUN STCTTS We

TELEPHONE: MUNDESLEY MEDICAL CENTRE FAX: MUNHAVEN CLOSE MUNDESLEY NORWICH NRI1 8AR Re: Regulation 28 Notification, Mr Darren Lee Arnoup A neuropsychological report from the Colman Centre dated 21.05.13, makes reference to the suicide attempt in September 2012. This report was not passed to GP as it was documenting historical information and it goes on to say "at this time (ie
2013) Mr Arnoup denied any intention to kill himself" . 2 We received a copy of a letter (as did Norfolk Recovery Partnership, NRP) on
12.06.13 from the Colman Centre addressed to the Access and Assessment Team (AAT) mental health care trust; This documented previous self-harm and suicidal ideation; however as referral was being made between the 2 agencies (the Colman Centre and the AAT) and only being copied to the GP with no action indicated; this was filed by an administrator: In addition, Mr Arnoup had been assessed by the AAT on 06.09.13 and there was no mention of any past or current suicidal ideation or deliberate self-harm in a letter to Mundesley Medical Centre, No formal follow up was arranged by the AAT but he was directed to self- referral into the Wellbeing Service if required If at this point this letter had alluded to a current risk of suicide or required any action for onward referral by the GP , this letter would have been passed to a doctor for review, rather than reviewed by an administrator and filed. As well as reviewing and reflecting on our internal processes; we also decided to request an external medical records review by Jackie Schneider, Head of Quality and Patient Safety at the CCG. This is enclosed for your perusal. Her recommendations which are listed below will be implemented. Recommendations for consideration 1 Develop clear lines of communication with NCH&C staff to ensure that where feel that relevant details have documented within the shared record that believe GPIPractice should be party to and that they ensure they alert and where possible summarise actions/concerns for clarity. 2 Due to the nature and impact of Mental health illness and substance abuse upon physical health and variability of risk factors and coping strategies for patients, if other professionals contact the practice to inform that & referral has been made in relation to these areas the GP should be alerted s0 that any subsequent consultations can be undertaken with this awareness Safeguarding/Domestic violence concerns highlighted should also be managed in the same way: Contd overl. May` they been they

TELEPHONE: MUNDESLEY MEDICAL CENTRE FAX: MUNHAVEN CLOSE MUNDESLEY NORWICH NRI1 8AR Re: Regulation 28 Notification, Mr Darren Lee Arnoup 3 Where other medical input highlights substance misuse (.e. reports following admissions) this could impact upon the support or prescribing offered at future practice consultations therefore consider making GPhursing staff aware. While understanding the limited timeframe of appointments and therefore ability to document consultation details, ensure that GPs make as full a history of any areas of mental upset or likely personal life instability discussed for the information of successive colleagues_ In addition we have amended our procedures and protocols as surnmarised below: 1 A GP will always be informed if a referral is made directly to the mental health service from an outside agency _
2. In consultation with a patient with mental health problems or those already under the care of the mental health service, GP will review any relevant documentation, reassess the risk of self-harm, consider onward referral to mental health service and record this in the medical record. 3 We have highlighted to all staff the importance of sharing information about vulnerable people at risk of suicide and deliberate self-harm and such correspondence will now be shown to a GP. 4 We are reviewing the use of filters on the SystemOne computer system, to make sure that relevant information is visible to the user This case has highlighted the problem with the amount of data and how it is shared within the wider NHS, It is evident that the CCG have concerns about how other organisations infomm us of 'at risk' palients A clear summary of findings or actions taken is usually difficult to identify. This sad case has provided an opportunity for us to close any gaps and continue to strive to provide the best care for our patients_ We understand the concerns of the family and the coroner and our ultimate aim would be that this review would help prevent any future deaths Contd overl . _ the

TELEPHONE: MUNDESLEY MEDICAL CENTRE FAX: MUNHAVEN CLOSE MUNDESLEY NORWICH NRI1 8AR Re: Regulation 28 Notification; Mr Darren Lee Arnoup If there are any areas in our reply that you feel that we have not addressed, please contact uS again Voure_cincorol

NHS North Nortolk Clinical Commissioning Group Mundasley Medical Centre Medical records system review Process Currently clinical records at Mundesley Medical Centre are elactronically maintained wilhin SystmOne which provides a sharad recording systam across participating clinicians and organisations, in (his instance the GP practice and staff employed by NCH&C. While the system allows multi-profesgional input, depanding on patient permissions sought and provided and any filtors applied (his can lead to entrieg being made, but which may not be available to be viewed by others. This may mean (hat Itie praclice are not aware Ihal consultations have laken place or (heir outcomes_ Internally Ihe practice provides a slick process of managing information letters that are sent to them: All reporls are "scanned up" and read fully by experienced medical secretaries who identify aclions or current clinicallsafety issues which have been raised wilhin the reports with working day of receipt: are than raised as actions t0 relevant clinical staff for Ihem to acknowledge and confirm that (he issues have been noted or completed. However this would not capture inforalion which has been added to systmOne by other participants: Many of Ihe reporls and informalion receivad by the practice is long and detailed It is accepted that for clinicians to undertake the role of fully reading all reports and letters received would have a serious impact upon their patient facing time and may result in detailslacllons being missed as they can become diffioult to oul of (hie body of reporls if nol thoroughly reviewed, Relevant ib8ue8 Within the case reviewed it was evident that the Practice had some low level intermittent involvement wilh Ihe patient; while the Neuro-rehab team (NCHRC) had been actively consulting with lhe patient and his wife for & number of months, however as there was no alert t0 the practice regarding lhe frequency, level or outcomos from their input it would have been unlikely that the praclice would have recognised the need to note or review detaile being recorded In June the Neuro ~rehab team wrote lo the GP to inform that they had made a referral for the patlent re: a mental heallh assessment and 9 referral to Norfolk Recovery Partnership for support with Alcohol misuse Within Ihe body of the letter commonts were made regarding the patients previous risk of self-harm from some years earlier: As the letter indicated this was an historical problem and that referral to Menlal health and NRP were made, this information was not actionad for the GP to review a8 it was felt there was no further action required by (he practice at Ihat point: and They pull being

The patient had been admitted (o hospital as an erergency on 3 occasions, 0 each occasion (he discharge letter was summarised and entered on to SystmOne by the secrelaries; the letter highlighted that the patient had suffered seizures due to Use Or withdrawal from alcohol, Again only if actions for the GP were identified would this have been reviewed, there by the possibility of the GP missing knowledge around substance misuse which might affect future treatment or support, The patienl had on a number of occasions (3-4) during May-Oct allended practice, wilh the exception of occasion this was to request a sick note or script nothing more in-depth: Only 1 consultation was there any indication that tho palient had disclosed any upset or dislurbance within hig personal lifa. The GP mada very mlnor reference lo this, and it was difficult to determine frorn documentalion Ihe level of concern that the palient had disclosed, so would have been difficull for colleagues to have picked up any salient issues in future consultations: Recording8 from NCH&C rehab team were found to be long and descriplive, included high level of informalion regarding the patient's partner (perhaps inappropriately recorded on his records?), and did not identify any clear summary of lindings or actlons laken_ It is unclear whether NCH&C clinicians believe (hat the GP practice accobses reads all of (heir documentation or inlends Ihem to. Recommondations for consideration Develop clear lines of communicalion with NCHRC staff to ensure that where (hey feel Ihat relevant details have bean documented wilhin Ihe shared record that believe GPIPraclice should be parly to and that ensure they alert &nd where poggible summarise aclionslconcerns for clarity 2 Due to nature and impact of Mental health illness and substance abuse upon physical health and variability of risk factors and coping strategles for patients, if other professionals cortact the practice to inlorm that & referral has been made in relalion to these areas GP should be alerled s0 that any subsequent consultations can be undertaken wilh lhis awareness Safeguarding/Domestic violence concerns highlighted should also be munaged in the same way:
3. Where other medical input highlights substance misuse (i.e. reports following admissions) ttiis could impact upon the support or prescribing offered at future practice consultations therefore consider making GPInursing staff aware_ While understanding the limniled timeframe of appointments and therefore abilily to document consultation details, ensure that GP's make a8 full a history of any areas of menlal upsel or Iikely personal life ingtability dlscussed for Ihe information of guccessive colleagues_ during and Ihey, they (he Ihe

Nurge Member of goveming body 12/05/14