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SAR Mr AA Case Summary for GPs

A Case Summary of Mr AA Outlining Learning for General Practice

Mr AA was a 42yr man who had been diagnosed with paranoid schizophrenia in 2005. He lived alone and had weekly contact with his sister for a family meal. He was under the care of the mental health team and had been managed under a CPA (Care Plan Approach) 2007-2011. This continued in a reduced capacity until July 2013. When he was discharged from his CPA he was felt to be stable and compliant with medication. At the same time his weekly prescription for venlafaxine was reduced and stopped over 2 weeks. This meant he no longer attended his GP practice to collect his weekly script. Instead his care was managed by the Clozapine clinic. On 2.12.13 he collected a month's supply of Clozapine which should have been sufficient to take him to the 13.01.14. However, he walked to the Clozapine clinic on the 6.01.17 advising he had not taken his medication for 4 days and complaining of diarrhoea and vomiting. Voluntary admission to a care home was arranged the next day so his Clozapine could be re-titrated.  

He was admitted to the care home on the 7.1.14 but his behaviour became more and more disturbed and he was placed under a Section 2 of the Mental Health Act on the 11.1.14. He was eventually transported in a full restraint prone position with a police escort to Ipswich later that day. He was placed in seclusion but under frequent observation until 16:30 when he was noted not to have moved since he was last observed at 16:16: staff entered the room and he was found to be unresponsive. He received CPR and was transferred to the DGH but his life support systems were switched off 5 days later on the 17.1.14. A post-mortem concluded that he had died from brain damage as a result of cardiac arrest and pneumonia.

Learning Points for a GP

We all have these complex mental health patients on our lists. There care is often managed by the mental health care trust and our role is to facilitate the supply of appropriate medications which would also include monitoring compliance. We often have little face to face contact and rely on secondary care to keep us informed.  When Mr AA's venlafaxine was stopped by secondary care in July 2013, 6 months before his death, this blocked a potential window into his life. As we have moved to electronic prescribing, these patients can now go directly to the pharmacies for their medications so there is even less contact. Would clearer channels of communication between GPs, mental health teams and pharmacists help future patients like Mr AA? I am in the process of discussing this issue with the Local Pharmaceutical Committee (LPC) but any suggestions or evidence of a good practice which is working would be greatly received to support this work.

What could have been done differently?

Were there any scheduled reviews of Mr AA's mood to monitor his response to the withdrawal of his antidepressant? If he failed to attend these reviews, was there any follow-up to see why?

What is a Care Plan Approach (CPA)? (1) This is a care pathway applied by mental health workers which is used to support patients with complex mental health issues. GPs are requested to report any known failed hospital appointment encounters (DNAs) for these patients as these can be a symptom of deteriorating mental health.  There is a code/flag on System One for these patients. Mr AA was discharged from his CPA at the same time as his medication was changed (this has been a separate action for Mental Health Secondary Care from the SAR).  When we receive notification that our patient has been "removed from their CPA" should this be a trigger us to make contact with these patients and arrange a period of review to make sure they remain well?

When a patient with known significant mental health disorders fails to attend a scheduled GP appointment, should we make enquiries to find out why? Should these patients be flagged? It could be the only clue to a deterioration in their mental health. In my surgery, for example, we are allotted an appointment at the end of the day which is specifically to check the DNA patients to see if we feel these patients require chasing as we have a high number of mental health patients.  Could we involve our "linked primary care mental health care workers" when in post? They may well be best positioned to follow up.

Potential actions

Consider auditing or reviewing your mental health care register? How many are currently on a CPA? Are they correctly flagged? Do your administration staff know how to code these patients and what is our duty of care to these patients?

Do your prescription teams notice and flag changes in compliance? Do our linked pharmacies report any evidence or suggestion of reduced/non-compliance with their medications?

When you receive a discharge notice from mental health care, be it from inpatient care, home treatment or from a CPA, do you have systems to arrange a follow-up? Is there a clear primary care care-plan? If these patients have been discharged from secondary care, they are now the responsibility of primary care and it could be said that it is our role to make sure these "adults at risk" are followed up by us.



Care for people with mental health problems (Care Programme Approach) - NHS (