A HEREFORD GP surgery has spoken out after a mental health patient told to wait four to six weeks took his own life. 

An investigation was opened into the death of Ronald Leslie Harris on June 14, a prevention of future deaths report issued by Herefordshire coroner Mark Bricknell said, with the inquest into his death concluding on September 27 with a verdict of suicide.

Mr Bricknell said that Mr Harris' wife had contacted Hereford Medical Group (HMG) on April 24 with regards to his mental health difficulties, the symptoms of which were said to be getting worse.

His family had raised concerns, requesting further help, but said a promised call from the surgery, which they had expected within five days, was not received and that a routine appointment was offered in four to six weeks.

The coroner said Mr Harris had later taken his own life on June 5, while his inquest raised concerns for the coroner about incomplete triage documentation.


In a response submitted in November, HMG said it uses an online system to record patient communication and online triage forms, and that triage information recorded by a receptionist had not saved correctly. Clinicians are now able to arrange to listen to phone calls when online forms are unavailable, the surgery said.

HMG said it believed Mr Harris' family had interpreted a receptionist telling them that the surgery would be in touch within five days as meaning a doctor would call within five days. Instead this delay was to allow for the triage form to be reviewed by a GP to determine whether an urgent, soon, or routine appointment was needed, HMG said.

The surgery said "significant measures" had been taken to reduce routine appointment waiting times by increasing the number of available appointments, with current waits at approximately four weeks. All triaging GPs are aware of how to find appropriate triage appointments, HMG said.

HMG said a significant event meeting in August reviewed the triage protocol but that no significant changes were seen to be needed except for making sure triaging GPs are aware of the next available routine and soon appointment slots.

As part of regular, ongoing GP training, it said, one lunchtime session in the next month will be on mental health, while the next protected education time in January will focus on triaging.