A HEATON surgery has been warned to take "urgent action" after failing to update a vulnerable patient's record with vital information.

A coroner said lives could be at risk if The Surgery, based in Heaton Medical Centre, did not improve its procedures.

Alan Walsh issued the warning following an inquest into the death of Frances Elizabeth Greenhalgh.

Ms Greenhalgh was found collapsed and unresponsive at her home on April 10.

The Lucy Street practice was reprimanded after failing to update her record with important information regarding care for her mental health.

The inquest into her death heard how the 52-year-old was admitted to Royal Bolton Hospital on March 22 after taking an overdose of medication.

She was referred to the Rapid Assessment Interface Discharge (RAID) Team which carries out mental health assessments and interventions at the hospital.

The assessment concluded that she was suffering from depression and could receive treatment through general practice.

After Ms Greenhalgh agreed to a care plan, the RAID Team faxed the details to her GP.

The plan included a GP monitoring her mood fortnightly, prescribing only seven days worth of medication to reduce overdose risks and self-referral to Bolton Integrated Drug and Alcohol Service.

The Surgery confirmed it received the plans from the team on March 22 but a locum GP, who later saw Ms Greenhalgh, said it was not updated on the practice's system until nearly two weeks later.

Unaware of the RAID team letter, the GP still prescribed seven days' worth of medication and made an appointment to see Ms Greenhalgh within the fortnight period.

An assessment of her mood went ahead on April 4. She died six days later.

The medical cause of death was found to be the combined toxic effects of the antidepressant mirtazapine and the pain killer dihydrocodeine.

Mr Walsh concluded the cause of death to be suicide and has written to the senior partner at The Surgery with concerns that future errors could result in patient deaths.

In his Prevention of Future Deaths report, Mr Gittins said: "During the course of the inquest the evidence revealed matters giving rise to concern.

"In my opinion there is risk that future deaths will occur unless action is taken.

"In my opinion urgent action should be taken to prevent future deaths and I believe that you have the power to take such action."

Action requested included the senior partner conducting a review of the practice's documented protocols and systems relating to processing and recording notifications from healthcare professionals and training and system checks to ensure notifications are recorded in patient notes.

The practice is under duty to respond to the report by November 7 detailing action it has taken.

The Surgery staff declined to comment.