Surrey

Noted (AI summary) NHS England highlights existing educational resources and guidance for GPs and outlines planned future actions including the rollout of the Learn from Patient Safety Events (LFPSE) service and implementation of the Patient Safety Incident Response Framework (PSIRF), and sharing the report with Regional Mortality Boards. Farnham Park GP Practice conducted a Serious Event Audit on 31 May 2022 and identified a clinical psychologist to provide mental health training. Unexpected deaths will be discussed at weekly clinical meetings. NHS Frimley ICB will share the coroner's concerns with GP practices, focusing on documentation of suicide/self-harm risk and mental health assessments. They will also update the local formulary to highlight national guidance on the increased risk of suicidal behavior when starting antidepressants, with a point-of-prescribing alert, to be completed by August 2022. CQC contacted Farnham Park Health Group and received evidence of a significant event analysis and action plan implemented in response to the death, with 7 of 10 actions already completed. They also raised the failure to notify CQC of the death with the provider and will consider further action. The GMC has reviewed the concerns and decided not to investigate further, but will share them with the doctor's responsible officer for discussion during their revalidation. The Department acknowledges the concerns and notes actions taken by other bodies, emphasizing the clinical responsibility of GPs in prescribing decisions and referencing NICE guidelines. It provides general context and reiterates existing guidelines without committing to specific new actions.

Noted (AI summary) The RCGP acknowledges the concerns, provides background on amiodarone, and recommends that the coroner request the MHRA comment on the matter as regulatory responsibility lies with them. The RCP recommends that no new monitoring systems are required for amiodarone, but that strict adherence to existing NICE and local shared care guidelines will provide for safe and monitored practice. MHRA will take forward the PEAG's recommendations to improve product information on pulmonary toxicity and consider additional risk minimisation measures, such as a Patient Alert Card, and issue a reminder to healthcare professionals via the Drug Safety Update.