Dear Ms Henderson Inquest into the death of Lee Hollman 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 Lee Hollman: 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 systems within a general practice for managing and monitoring the practice s interface with external organisations, records management and communications with colleagues The role_ofthe 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 approaching 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 enormous 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 set out below is solely to show you what we do in the context of training and advice to our Members Royal College of Oenoral Practitlonere 30 Eueton Squaro London NWI 2Fp Tol 020 3180 7400 Fax 020 3108 7401 Emall Info@redp org uk Wob WWW regp org Uk Patron; Hls Royal Highness Ihie Duke 0f Edlinburgh Regletered charity number 223100

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 and 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) http IIWWW rogp org Uklgp training-und- exams/gp curriculum_ overview aspX The death of Lee Hollman raises issues about the need for strictly accurate medical record-keeping in GP practices, GP workload, the need for close working relationships between GPs and pharmacists and the duty of the doctor to conduct regular medication reviews with patients as part of a sound practice repeat prescribing system. Best practice calls for patients with long-term conditions to be given medication review appointments at regular six-monthly or yearly intervals_ Record-keeping Addressing your concern about failures in maintaining accurate and updated medical records and, more specifically the failure to remove Trazodone from the repeat prescription record and the failure to delete the the 'old' dosage of Quetiapine from the record, the importance of accurate record- keeping is stressed in the section of The Curriculum entitled "Being a General Practitioner' http Ilwww rcgporg:uklgp-training-and-exams/~ImedialFiles/GP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-1-Being-a-GP ashx "This means that as a GP you should:
1.1.3 Use an organised approach to the management of chronic conditions
1.5 Make available to your patients the appropriate services within the healthcare system This means that as a GP you should:
1.5.2 Develop your organisational skills for record-keeping, information management;, teamwork, running practice and auditing the quality of care" The importance of record-keeping in the practice is further developed in the section entitled "Patient safety and quality of care" where you will also see highlighted the importance of close collaboration medical colleagues and other healthcare professionals http IlwwW rcgp.org uklgp-training-and-exams/~ImedialFilesIGP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-2-02-Patient-Safety-and-Quality-Of-Care ashx refer you to page 9 in particular: "1.13 Demonstrate an understanding of the connection between good data entry and improved patient health outcomes
1.14 Demonstrate how to use information management and technology (IM&T) to share information and co-ordinate patient care with other health professionals
1.15 Demonstrate an understanding of the need for information recorded in the practice clinical system to be fit for sharing with different health professionals in different organisations
1.23 Understand the concept of variation in clinical care, how it is determined and measured and what actions might need to be taken to address inappropriate variation, for example in referrals, prescribing, admissions
1. 30 Demonstrate an understanding of the principles of medicines management" Pages 10 and 11 further develop this theme: "This means that as a GP you should:
3.1 Compare the systems and processes in place in your practice to identify and manage risk in the primary care setting and compare these with other practices
3.3 Be aware of the limitations of your own skills in risk management and illustrate that you understand when the skills of colleagues trained more extensively in risk management should be called upon Royal Collere of General Praclillonere 30 Eubton Square London NWI 2FB Tol 020 3188 7400 Fax 020 3100 7401 Emall Info@regp Org uk Wob WWW rCOP,Ord Uk Patron: Hie Royel Highness (he Duke 0f Edlinburgh Registered eharity number 223/00 key with

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4.2 Reflect on the risks to patient safety in a care pathway in which a variety of healthcare professionals are involved, looking at interface issues and be able to comment on the ways in which, as a GP, you can work to minimise these' Other sections of The GP Curriculum of particular relevance in this case are given below: "3.10 Care of people with mental health problems http Ilwww rcgporg uklgp-training-and-exams/~ImedialFiles/GP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-3-10-Mental-Health-Problems.ashx" This section includes the need for the general practitioner to be able to assess and manage risklsuicidal ideation.
3.14 Care of people who misuse drugs and alcohol Section 3.14 of the GP Curriculum on the Care of people who misuse drugs and alcohol, whilst not directly relevant; highlights some interesting points about GP awareness of prescribing problems http Ilwww rcgporg uklgp-training-and-exams/~ImedialFilesIGP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-3-14-Drug-and-Alcohol-Misuse.ashx" In particular, the general practitioner should: "3.1 Always be aware of possible drug- or alcohol-related problems with almost any presenting problem or prescribing issue
3.4 Be aware of common long-term effects of drug and alcohol misuse including reasons for drug- related deaths
3.6 Be aware of urgent and important issues of safety including risks to self or others and the need for urgent medical or psychiatric care Relationship between GPs and Pharmacists The tragic death of Lee Hollman highlights the need for GPs and Pharmacists to work closely together. At its meeting on 18 June 2011, the RCGP Council approved a joint statement drawn up by RCGP members and the members of the Royal Pharmaceutical Society setting out guidelines for good working relationships between GPs and pharmacists: A copy is attached to this letter as an appendix You will see from the paper that one of the "building blocks for change" suggested is: Better transfer and sharing of patient information facilitated by improved inter-professional IT links_ Repeat Prescribing Guidance for doctors, including general practitioners, on repeat prescribing is set out in the GMC's document: Good practice in prescribing and managing medicines and devices (2013)" http /Lwwwsgme-ukorg/guidancelethical_guidance/ L43 "Prescribing guidance: Repeat prescribing and prescribing with repeats" http:/Iwwwemc-ukog/guidancelethical_guidance/ L4325a8p Relevant extracts are set out below: "55_ You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues so you must make sure that any repeat prescription you sign is safe and appropriate You should consider the benefits of prescribing with repeats to reduce the need for repeat prescribing: Royal Collede of General Pracllllonere 30 Euston Square London NWA 2FB Tel 020 3180 7400 Fax 020 3188 7401 Emall Info@regp org Uk Wob WWW rCOP Ord Uk Patron: Hie Royal Highnegs the Duke of Edinburgh Rogieterod charity number 223100
16.asp

56 As with any prescription, you should agree with the patient what medicines are appropriate and how their condition will be managed, including a date for review: You should make clear why regular reviews are important and explain to the patient what they should do if
a. suffer side effects or adverse reactions, or
b. stop taking the medicines before the agreed review date (or a set number of repeats have been issued) You must make clear records of these discussions and your reasons for repeat prescribing 57 . You must be satisfied that procedures for prescribing with repeats and for generating repeat prescriptions are secure and that:
a. the right patient is issued with the correct prescription
b. the correct dose is prescribed, particularly for patients whose dose varies during the course of treatment
c. the patient's condition is monitored, taking account of medicine usage effects
d. only staff who are competent to do so prepare repeat prescriptions for authorisation patients who need further examination or assessment are reviewed by an appropriate healthcare professional
f. any changes to the patient's medicines are critically reviewed and quickly incorporated into their record_
58. At each review, you should confirm that the patient is their medicines as directed, and check that the medicines are still needed, effective and tolerated. This may be particularly important following a hospital stay, or changes to medicines following a hospital or home visit: You should also consider whether requests for repeat prescriptions received earlier or later than expected may indicate poor adherence, leading to inadequate therapy or adverse effects_ 59_ When you issue repeat prescriptions or prescribe with repeats, you should make sure that procedures are in place to monitor whether the medicine is still safe and necessary for the patient: You should keep a record of dispensers who hold original repeat dispensing prescriptions so that you can contact them if necessary. hope you find these comments helpful.

Dear Sir,

Background to the Regulation 28 Report

I write following the Coroner’s inquest into the death of a former patient, Lee Hollman, who died on 23rd February 2013. The inquest was undertaken by the Assistant Coroner, Dr Karen Henderson, on 13th March 2014 at Horsham Magistrates Court.

Riverside Surgery was named as an Interested Person by the Coroner and I attended to provide an account of the care provided to Mr Hollman.

During the course of the inquest, the Coroner noted a number of matters which, although not causative of Mr Hollman’s death, were of concern. I refer you to a copy of my letter to the Coroner dated for full details of the background to this case.

The Coroner concluded that Mr Hollman took his own life and issued a report under Regulation 28 to prevent future deaths in relation to Riverside Surgery’s Riverside Surgery w w w . r i v e r s i d e s u r g e r y h o r s h a m . c o . u k

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Riverside Surgery w w w . r i v e r s i d e s u r g e r y h o r s h a m . c o . u k

prescribing policy. I enclose a copy of the Regulation 28 Report, as directed to the CCG and Royal College of General Practitioners (RCGP).

NHS England Invovlement

Soon after the event of Mr Hollman’s death, the surgery met and submitted a Significant Incident Report. Copies of this report have been forwarded on to The Surrey and Sussex Area Team of NHS England as well as to the CCG.

Prior to the Coroner’s inquest I disclosed my involvement to my appointed Responsible Officer , and self-referred to the Performance Screening Group of The Surrey and Sussex Area Team of NHS England. I have also discussed my professional performance with my Clinical Appraiser

Addressing the Coroner's concerns

As a surgery we are keen to learn from this tragic event and have reflected at great length on the medication errors which occurred. The policy for the issuing of repeat medications has been reviewed and re-written, particularly in respect to psychotropic medications. I enclose the new policy for your review.

We recognise that patients on psychotropic medications are vulnerable, may have altered awareness, suffer compliance difficulties and may exhibit suicidal ideation. Therefore, increased vigilance and review of these medications is required. The new process for providing a patient with psychotropic medication provides an additional review by the prescribing doctor to ensure that the medication prescribed is at the correct dose and that risk of harm is reduced.

I have outlined below how the Riverside Surgery has addressed each of the areas of concern highlighted by the Coroner:

Riverside Surgery w w w . r i v e r s i d e s u r g e r y h o r s h a m . c o . u k

1. Failure to maintain sufficiently accurate and updated medical records.

The medication prescribing process for patients under the care of the CMHT has been revised in the following key respects:

1. Upon seeing a patient recently reviewed by the CMHT, we consider whether we are in possession of the most up to date correspondence and record any issues arising. This informs further collaboration with the CMHT and promotes timely communication between the two organisations.

2. Correspondence received from the CMHT is sent to the GP responsible for ongoing prescribing of medications. The Repeat Prescribing Policy stipulates that any change in medication for a patient under the care of the CMHT may be made only upon receipt of correspondence from the CMHT confirming the new prescription. Any medication change is then recorded in the patient records.

3. When a repeat prescription is stopped, the clinical IT system (TPP SystmOne) requires the user to input the reason why that repeat has been stopped. This reason will subsequently reappear when any attempt is made to reinstate the repeat prescription. This will prompt the reviewing GP to check the recent medication list on the surgery’s clinical IT system against the CMHT medication list.

These processes ensures that information about a patient’s mental health medication is contemporaneous. Thus ensuring the medical records are accurate and can be relied upon to guide the prescribing of medication safely.

Riverside Surgery w w w . r i v e r s i d e s u r g e r y h o r s h a m . c o . u k

2. Failure to remove Trazodone from the repeat prescription record.

The new measures outlined above ensure that any changes to prescribed medications are properly recorded, with reasons given. The new system also promotes increased vigilance of medication changes by the CMHT. Increased communication with the CMHT ensures that the correct medications are prescribed and issued to the patient.

3. Failure to delete the old dosage of Quetiapine from the relevant medical records.

The key aspects of the new procedure are as follows:

1. There is now a restriction of psychotropic medication to 1 month of issue. Previously such medication could be issued for up to 6 months at a time. After each month a GP is required to re-issue the medication. During this process, the GP will review the prescription in light of the most recent clinical correspondence from the CMHT. Administrative staff can no longer print out an authorised repeat of medication.

2. We have updated the IT system to reinforce the policy. To illustrate this, I enclose screen shots showing the stages of the issuing process. The intention of this change is to reduce the risk of human error.

3. A GP now reviews the medication being prescribed whenever relevant correspondence is received by the CMHT or when the patient requests medication. This increases the number of reviews by a GP to ensure the correct medication and dose are prescribed at the correct time.

Riverside Surgery w w w . r i v e r s i d e s u r g e r y h o r s h a m . c o . u k

4. The lack of an effective system to issue repeat prescriptions.

The revised repeat prescribing protocol addresses concerns about the issuing of the repeat prescriptions. This has been disseminated to all clinical and administrative staff, with a change in the Clinical IT system functioning to support the correct implementation of this policy.

The coroner raised particular concerns regarding the Duty Doctor having to sign all the repeat prescriptions for a particular day. We have subsequently reviewed this practice and now have allocated the signing of prescriptions to the issuing GP, who is likely to be more familiar with the patient and their medication. The significantly reduces the number of prescriptions that each GP will sign on any given day by 66-80% (based on 3-4 GPs on duty).

Prescriptions that run onto multiple sheets will be stapled together, so to avoid being separated. This is important for ensuring that multiple doses of the same medication are visible for review when signing.

5. Failure to review patients within their own guidelines with regard to repeat prescriptions.

Throughout the year the GP’s have and continue to hold specific Mental Health Reviews. In the most recent Quality Outcome Framework (QOF - 2013/2014) review of our clinical records confirmed that reviews were being carried out in accordance with the relevant guidelines.

Increasing our communication and collaborative working with the CMHT is ongoing. Increasing the number of steps in the issuing of mental health medications produces a higher number of reviews of the patient record and their medications by the GP.

Riverside Surgery w w w . r i v e r s i d e s u r g e r y h o r s h a m . c o . u k

In addition to the annual mental health review performed by the surgery, there are regular reviews in different forms that mental health patients receive. These are review of specialist consultations through correspondence submitted by the CMHT, case review meetings with the Mental Health Liaison Practitioner and face to face reviews with the patient. This translates to ongoing and regular review of those patients with mental health problems seen by the CMHT along established practice guidelines.

Improved liaison with the Community Mental Health Team

The practice met with representatives from the Horsham Community Mental Health Team (CMHT) on 10th March 2014 to discuss care of patients and to improve communication between our two organisations. We are also due to meet shortly with the recently appointed Consultant Psychiatrist

I enclose the minutes of our recent meeting with our Mental Health Liaison Practitioner.

a GP at the practice, has been in contact with Ms. Prescribing Advisor, Medicines Management Team at the Horsham & Mid Sussex CCG to discuss further the prescribing of mental health medications, the communication between Horsham CMHT and Riverside Surgery. We are expecting further communication from ATS Clinical Lead NWS for Sussex Partnership NHS Trust in this regard.

Conclusion

We hope that the changes introduced at the Riverside Surgery and referred to above will prevent any repetition of the errors that occurred in this case. The processes we have adopted and are in the process of adopting will reduce risk and significantly reduce the chance of similar problems from recurring.

Riverside Surgery w w w . r i v e r s i d e s u r g e r y h o r s h a m . c o . u k

We have significantly modified our policies and processes to safeguard our patients safety and to promote high quality patient care at Riverside Surgery.

On behalf of Riverside Surgery,