A Sutton GP practice branded ‘unsafe’ following the death of a 41-year-old woman had been closely monitored by NHS chiefs as far back as 2007, an inquest has heard.
In October, Nottinghamshire coroner Mairin Casey suspended an inquest into the death of Samantha Carmichael following concerns raised about the Pantiles Medical Centre, on Church Street, Sutton – run by Dr Qudsia Chandran and her husband Dr Raj Chandran – to allow for consultation with senior health officials.
Mrs Carmichael, of Carsic Lane, died on 22nd April following what is believed to have been an accidental drugs overdose.
But doctors at the centre came under fire after it emerged that in January the practice had taken 16 days to make an urgent referral for Mrs Carmichael to mental health specialists after she told staff ‘she thought she would be better off dead’.
NHS guidelines dictate that urgent mental health referrals should be made within 24 hours.
At the first hearing Dr Sivaram Sathasivam, the GP who saw Mrs Carmichael, said the surgery’s operational practices were completely unsafe and that he had passed on his concerns to management.
The practice had been run by husband and wife Dr Raj Chandran and Dr Qudsia Chandran until 2010, when Raj Chandran retired - leaving his wife in sole managerial control, the inquest heard.
But at the reconvened hearing on Thursday 28th November, it emerged that the practice had been under close supervision for six years and had repeatedly fallen back into bad practices following inspection visits.
Giving evidence at the hearing, Dr Qudsia Chandran initially said that the referral had taken so long because the surgery had been having problems with its former practice manager, who had left shortly after Mrs Carmichael’s visit.
But when Ms Casey said that Dr Doug Black, from HNS England, had informed her in writing about their ongoing concerns about the Pantiles practice, Dr Chandran blamed her husband, who was sitting with her in court.
She said that Dr Raj Chandran, a former police surgeon and candidate for Nottinghamshire Police Commissioner in 2012, had been solely responsible for the running of Pantiles until his retirement in 2010.
Ms Casey said: “Dr Sathasivam joined the surgery in 2012 and immediately raised concerns about practices and drew it to your attention. If you are a partner in a GP practice, shouldn’t the safety of your patients be a priority? Isn’t that a given?
“What failed Samantha was the systems of this practice and not Dr Sathasivam. I can’t see that this doctor dealt with Samantha in any way that would lead me to question the quality of his care.
“The problem wasn’t the referral but that his plan failed because the systems that were in place were unsafe.”
After the first hearing was adjourned, the Pantiles Medical Centre drew up a new protocol to deal with the referral of patients with mental health needs.
But Ms Casey ruled that this document was still inadequate and adjourned Thursday’s hearing for an hour to allow Dr Chandran and lawyers representing the practice to redraft it to an acceptable standard. She gave them until Monday to produce a final version.
She also ruled that the new protocol must be made available to all permanent and locum staff working at Pantiles, and that NHS England would continue to monitor its progress.
Jackie Swann from NHS England (Derbyshire and Nottinghamshire) said: “NHS England ensures all GPs work to agreed standards, which are regularly monitored. Where service standards are not being met, NHS England will take action to examine why. It is not possible to make individual comment about live or ongoing investigations.”
Pantiles Medical Centre is expected to merge with the Willowbrook Medical Practice, in Brook Street, Sutton, later this year, the inquest heard.
Nottinghamshire coroner Mairin Casey recorded a verdict of death by misadventure at the inquest into the death of Samantha Carmichael.
A number of drugs were found in the body of Mrs Carmichael, 41, of Carsic Lane, Sutton, following her death on 22nd April.
Amphetamine and Dosulepin were amongst those drugs found in her system, but the pathologist and bio-chemist who carried out a post-mortem examination could not establish which drugs caused her death.
Ms Casey ruled that the poor care she received at the Pantiles Medical Centre did not contribute towards Mrs Carmichael’s death, and that she had not returned to the health centre following the first appointment.
But the hearing was told that under NHS guidelines, her case should have been referred urgently by Pantiles to specialist NHS workers within 24-hours, who should have seen her within two weeks.
The surgery should also have arranged a ‘safety net’ follow-up appointment for Mrs Carmichael, and should have seen her again within seven days of her first appointment.
She also stated that it was not appropriate for locum doctors and administrative staff to be making key clinical decisions.
Recording the verdict, the coroner said there was not sufficient evident to rule that Mrs Carmichael had taken her own life.