Report for Coroner Dr. Eleanor Vance
Concerning the Coronial Inquest into the death of Mr. David Miller
Mr. David Miller was a registered patient at our medical practice from 2018. I was his general practitioner, providing ongoing primary healthcare services and supportive medical care from 12th January 2018 until 10th October 2024, when he sadly passed away.
Summary of Medical and Mental Health Background:
Mr. Miller had a history of depression, diagnosed in 2019. He was also diagnosed with hypertension in 2021, which was managed with medication. He reported occasional alcohol use, but denied any substance abuse.
Symptoms, Investigations, and Outcomes:
Mr. Miller presented with increasing fatigue and low mood in the months leading up to his death. Blood tests were conducted, revealing slightly elevated liver enzymes, but no definitive diagnosis was made. A referral to a gastroenterologist was pending.
Medication Changes:
Mr. Miller's antidepressant medication, Sertraline, was increased from 50mg to 100mg daily in July 2024 due to worsening depressive symptoms. His antihypertensive medication, Lisinopril, remained unchanged.
History of Suicidality:
Mr. Miller reported suicidal ideation on several occasions, particularly during periods of low mood. He had a previous suicide attempt in 2020, for which he received counselling.
Mental Health Treatment and Referrals:
Mr. Miller received regular counselling sessions with a local therapist. He was also referred to a psychiatrist in 2020 following his suicide attempt, but did not attend the appointment.
History of Alcohol or Drug Abuse:
Mr. Miller reported occasional alcohol use, but denied any substance abuse.
Last Consultation:
Mr. Miller's last consultation was on 5th October 2024. He reported feeling increasingly hopeless and fatigued. The plan was to review his blood test results and follow up with the gastroenterologist referral. He was also encouraged to continue with his counselling sessions.
Stressors:
Mr. Miller reported significant stressors, including ongoing physical health symptoms and lack of a definitive diagnosis, which contributed to his low mood.
Mental Health Act Status:
Mr. Miller was not under the Mental Health Act.
Further Information:
Relevant documentation, including clinical notes and blood test results, are available for review. All clinical notes from January 2024 to October 2024 are included.
Sincerely,
Dr. Sarah Jones
MBBS, MRCGP
123 High Street, Anytown, UK
Report for Coroner [Name of Coroner] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Concerning the Coronial Inquest into the death of [Name of Deceased] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Name of Deceased] was a registered patient at our medical practice from [Year] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.). I was [his/her/their] general practitioner, providing ongoing primary healthcare services and supportive medical care from [Start Date] until [End Date], when [he/she/they] transferred to [New Medical Centre] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.).
Summary of Medical and Mental Health Background:
[Describe the patient's medical and mental health background, including any significant history of mental health issues, chronic conditions, and other relevant medical history.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Symptoms, Investigations, and Outcomes:
[Describe the patient's symptoms, any investigations conducted, and the outcomes of those investigations.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Medication Changes:
[List any changes in the patient's medication, including the names of the medications, dosages, and reasons for the changes.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
History of Suicidality:
[Describe any history of suicidal thoughts and behaviours, including any specific incidents and interventions.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Mental Health Treatment and Referrals:
[Detail the patient's mental health treatment, including any hospital admissions, treatments, and referrals to mental health professionals.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
History of Alcohol or Drug Abuse:
[State any history of alcohol or drug abuse, if applicable.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Last Consultation:
[Describe the patient's last consultation, including the date, presenting symptoms, and any treatments or referrals made during that consultation.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Stressors:
[Describe any significant stressors affecting the patient, including physical health symptoms and lack of a definitive diagnosis.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Mental Health Act Status:
[State the patient's status under the Mental Health Act, including any compulsory orders and relevant details.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Further Information:
[Include any additional relevant information, such as documentation, clinical notes, reports, and referrals for a specified period prior to the patient's death.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Sincerely,
[Insert practitioner name]
[Insert practitioner credentials]
[Insert practitioners address]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)