Guidance

Introduction

Patients who exhibit habitually unacceptable behaviour can be a common problem in general practice. Examples may include abusive, aggressive or threatening behaviour and includes verbal and others means (such as letters, emails, social media postings). It will also include unacceptable use of language, such as swearing or inappropriate sexual references or actions.

Handling such behaviour puts a huge strain on time and resources and causes unacceptable stress for staff, who may need support in difficult situations. The following guidance has been developed by the LMC to reflect guidance from a number of sources including NHSE, the BMA and the GMC.  It aims to provide practices with guidance on issuing warning letters and behaviour contracts to patients whose behaviour is unacceptable.

The vast majority of patients do not display such behaviour, these guidelines are for the small minority who do and should only be used on an exceptional basis.

The procedures outlined in this document should only be used as a last resort and after all reasonable measures have been taken to try to resolve issues at informally practice level or formally through the NHS complaints procedure. Judgment and discretion must be used in applying the criteria to identify such behaviour and in deciding on the action to be taken in each case.

Practices should consider this guidance alongside their complaints and zero tolerance policies.

Please see Section 2 for sample warning letters.

Practices should consider the below guidance alongside their complaints and zero tolerance policies.

You may also wish to read our webpage on “Removing Patients from Practice Lists”

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Warning Letters

Warnings do not have to be in writing, but it is good practice for them to be so, as this allows for carefully considered reasons to be given.

Letters should include:

  • Name and role of person sending letter (we recommend that this is usually the Partners).
  • Brief description of the behaviour or incident.
  • Details of any previous steps taken to address the behaviour.
  • Say why the behaviour is unacceptable and the impact it has had on staff, other patients or NHS services.
  • Set out what will happen if behaviour repeated (this may include de-registering the patient from the practice on the grounds of an irrevocable breakdown in the relationship should the unacceptable behaviour be repeated within the next 12 months, in line with the NHS (GMS) Regulations).
  • Say who will be informed or copied in (if applicable – see GMC guidance).
  • Advise that a record will be made of the incident (this may be in a significant event log for example!)
  • A record of the warning (including the date and reason for the warning) must be given and retained as the ICB/NHSE may require sight of them. Copies of such records must therefore be retained after the patient has left the list.
  • Provide information on how decision may be challenged and details of the practice’s complaints process.

Note:   No warning is required if the practice has reasonable grounds for   believing that:

  • the issue of such a warning would be harmful to the physical or mental health of the patient;
  • the issue of such a warning would put at risk the safety of members of the practice or those entitled to be on practice premises;
  • it is, in the opinion of the practice, not otherwise reasonable or practical for a warning to be given.

Reasons for Checklist Items 

Name and role of person signing/sending letter:
The issue of a letter by a person(s) not connected with the incident (or delivery of care) may help to divert the behaviour away from those who provide treatment or care to the person involved. It may also help show how seriously the incident or behaviour is being taken. 

Brief description of the behaviour or incident:

Sufficient information should be given to identify the behaviour/incident however, as the letter will be sent to the person concerned there is no need to go into significant detail at this stage.

Impact of behaviour:

Some individuals may not be aware of how their behaviour has affected those subjected to it and how dealing with the behaviour may have impacted on the delivery of services. Where there has been an impact on services (e.g. longer waits for others, misuse of emergency ambulance etc.) this should be clearly stated.

Result of further behaviour:

It is essential to warn the person about the possible further action that may be taken should the unacceptable behaviour be repeated. There are a number of possible actions depending on the nature and extent of the behaviour in question. These may include:

  • De-registration from the practice list
  • Restriction on entry to premises
  • Provision of services at another location
  • Reporting to police where the behaviour may be a criminal offence
  • Civil legal action to prevent a repetition of the behaviour

It is important to consider carefully whether it will be possible to take the further actions threatened, as failure to follow up may result in an escalation of the behaviour. 

Sharing information:

It may be necessary to share information with others regardless of what other action is taken.  This may be both in order to assess risk and to prevent other people or organisations from referring the person to premises from which the patient may have been excluded. The following questions help in reaching and recording decisions.

  • Do any other staff within your organisation, or in an external body need to know about the incident or the issue of the warning letter in order to protect themselves or others?
  • If so, how much information do you need to share to allow them to assess any risk?
  • How can this information be communicated securely?
  • What are the possible outcomes if the information is not shared? 

Records marking:

Where an incident of unacceptable behaviour has taken place consideration should always be given to whether the incident should be noted General advice is that this should be kept separate from the patients medical record (unless it relates to their medical condition). It may therefore be appropriate to add a flag to the record to alert staff that there is an issue.

A decision should also be made on whether other staff or organisations should be made aware in order to help them assess if they are at risk.

Reviews, Challenges and Complaints:

The decisions relating to the actions in this guidance, taken by health bodies, or

organisations providing NHS services are subject to a review or complaints process.

The seriousness of any incident and any risk posed by further behaviour will determine whether any warning remains in place pending the outcome of a review or complaint.

Additional Actions:

It is essential that staff are kept informed of what action is being taken. This will not only show that the organisation takes unacceptable behaviour seriously but will allow staff to anticipate any adverse reaction to the action from the individual concerned.

It may also be necessary to review any risk assessment where there may be future contact with the person(s) involved.

Actions Against Persistent or Nuisance Persons:

There may be occasions where the unacceptable behaviour does not take place face to face but by letter, telephone or other means of communication. In such cases it may not be necessary to restrict or prevent attendance at premises in person and alternative action may be required to address the behaviour.

The Local Government Ombudsman’s ““Guidance note on management of unreasonable complainant behaviour” makes the following suggestions:

  • Placing time limits on telephone conversations and personal contacts.
  • Restricting the number of telephone calls that will be taken (for example, one call on one specified morning/afternoon of any week).
  • Limiting the complainant to one medium of contact (telephone, letter, email etc) and/or requiring the complainant to communicate only with one named member of staff.
  • Requiring any personal contacts to take place in the presence of a witness.
  • Refusing to register and process further complaints about the same matter.
  • Where a decision on the complaint has been made, providing the complainant with acknowledgements only of letters, faxes, or emails, or ultimately informing the complainant that future correspondence will be read and placed on the file but not acknowledged. A designated officer should be identified who will read future correspondence.

As with the other actions outlined in this guidance any decisions are subject to a review process. Whether they should also be the subject of the complaints process will depend on whether any complaint is simply another method of revisiting the original or closed complaint.

Please click HERE to access the following examples of letters to patients:

  • letter to patient following alleged inappropriate behaviour
  • letter to patient following alleged repeat of inappropriate behaviour
  • letter when removal from a GP list is the preferred option

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Acceptable Behaviour Agreements

Acceptable Behaviour Agreement Letter Checklist:

Letters should include:

  • Name and role of person(s) sending letter.
  • Brief description of the behaviour or incident.
  • Details of any previous steps taken to address the behaviour.
  • Say why the behaviour is unacceptable and impacts it has had on people and services.
  • Set out under what type of behaviour is expected/not acceptable and if appropriate the conditions (if any) placed upon any future entry to premises.
  • Set out what will happen if conditions are breached or if behaviour repeated.
  • Say who will be informed or copied in.
  • Advise that a record of the incident has been made.
  • Give date when agreement will be reviewed.
  • Provide information on how decision may be challenged and details of
  • complaints process.

To ensure clarity and to assist in appropriate information sharing, it is recommended that the agreement should be set out separately from the letter. 

Conditions. . .

It is not possible to provide a list of conditions for every possible situation. There may however be some conditions which would apply to many cases, for example –

  • I will not use violence, or foul or abusive language or threatening behaviour towards any person while on NHS premises.
  • I will treat all staff, patients and visitors with courtesy and respect at all times.
  • I will leave the premises when asked to do so by staff.

A behaviour agreement is voluntary, and no one can be compelled to sign one, nor can a lack of response be taken as agreement. Conditions then can be tailored to the circumstances and because it is a voluntary agreement, conditions can be included which it may not be possible to use in any legal contract or court order. An example of this would be where a condition relates to agreeing to take medication as prescribed. 

In all cases the conditions of the agreement must be clear; the person signing the agreement must be in no doubt about the behaviour expected.

Issuing Letters. . .

It is essential that staff are kept informed of what action is being taken. This will not only show that the organisation takes unacceptable behaviour seriously but will allow staff to anticipate any adverse reaction to the action from the individual concerned.

Example – Acceptable Behaviour Contract

Example – Patient Behaviour Agreement

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Zero Tolerance Statement – Sample Wording

As a Practice we are very aware that visiting your GP can, at times, be stressful and concerning for patients. Delays in obtaining appointments and delays in surgery times, due to unforeseen emergency appointments, can also add to these concerns.

We always strive to meet patient expectation and deliver the highest standards of healthcare. For the vast majority of our patients we achieve this, despite the finite resources and steadily increasing demand for services that exists today within the NHS. 

Our staff come to work to care for others, and it is important for all members of the public and our staff to be treated with respect.

In line with the rest of the NHS and to ensure this is fully observed we have instigated a Dignity at Work and Zero Tolerance policy, whereby aggressive or violent behaviour towards our staff will not be tolerated under any circumstances.

Anyone patient who verbally abuses a member of practice staff will be sent a letter from the Practice confirming that this behaviour will not be tolerated. Any future violation of this policy may result in removal from the Practice patient list. The Police will be called in all cases of violence.

The Practice feels sure you will understand that proper behaviour is absolutely necessary for our staff and patients and that non observance will not be accepted.

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Sample Independent Contractor Conciliation Process

Stage 1. . .

  • Find out what has happened and try to identify the cause.
  • Agree the process, e.g.
  • try to speak to the patient (informally / privately) at the time of the incident, or
  • invite them to the practice for discussion, or
  • write to them with the offer of a meeting to discuss the incident / behaviour (it may be useful to use a specially skilled or trained member of the practice to facilitate this)
  • During the meeting find out the reasons for behaviour / incident. Discuss the consequences of repetition etc. Keep a file note of discussions.
  • Considering inviting ICB/NHS England staff to advise / conciliate and / or contact other agencies if required. 

Stage 2. . .

Where repetition of incident / behaviour occurs, or improvement required has not taken place:

  • Send further warning letter (inviting comments as before).
  • Notify NHS England / ICB and consider outside intervention if not used before.

 Stage 3. . .

If there is a further reoccurrence:

  • Consider requesting the patient to be removed from the practice list/withdraw the provision of primary care services, giving reasons.
  • Notify patient of removal/withdrawal of services, giving reasons as appropriate, with reference to previous warnings.

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A Good Practice Guide – Violence and Aggression – GPs and their staff

 Definition of Violence:

The definition of work related violence is not subjective. Violence means: “any incident where staff are abused, threatened or assaulted in circumstances related to their work, involving explicit or implicit challenge to their safety, well-being or health” – European Commission DG-V 1997.

Legal Framework:

The legal responsibilities for employers to protect their staff are framed by both National and European health and safety legislation and by their common law duty of care.

Healthcare is integral to the communities within which they are delivered. Consequently, fostering good relations within the community and with organisations such as the police are important in reducing violence against staff in the NHS. The Crime and Disorder Act 1998 requires local authorities and police to co-operate with other bodies including NHS trusts to formulate and implement crime and disorder strategies.

Your Role:

The aim of this guidance is to establish YOUR security role. Whether you are a doctor, practice manager, nurse, administrator, receptionist, caretaker or cleaner, you have to be SECURITY CONSCIOUS. As a member of staff, it is your duty to keep your eyes open, look for unlocked doors and windows, challenge strangers, carry out security procedures thoroughly and report all incidents.

Assessing the Risk of Violence:

There is no single solution to preventing violence against staff working in primary care. However, there are tasks that can be carried out to help prevent such incidents. Prevention of violence at work must start with a full assessment of the risks. Risk assessment should be carried out by appropriately trained staff and should be complemented by a programme of action to reduce the risks. However, it is important to note that this should not be seen as a one off exercise but should be subject to ongoing monitoring and review to ensure the assessment is a true reflection of your current work situation. Be prepared to add further measures or change existing measures where these are not working. This is particularly important where the job changes. If a violence incident occurs, look back at your assessment, evaluate it and make any necessary changes. Practices should develop local prevention strategies. These should take account of the environment in which you are delivering the service, involve training of staff and an assessment of communication processes within your practice.

Environment:

The environment in which staff work, patients are treated, and other members of the public visit can have a significant influence on behaviour. You should consider assessing environmental factors such as cleanliness, light, temperature, the adequacy of space, control of access and signage, as well as the provision of eg private room(s). This will ensure that the physicality of a place doesn’t trigger or exacerbate a stressful situation.

The use of CCTV has also been well documented as a good disincentive to anti-social and/or unlawful behaviour.

Reception areas are often the first part of the practice that patients see. Naturally, many of the people who walk into a practice are either under a great deal of stress, in pain or very upset. The reactions of these people can therefore never be predicted. It is vital that we do everything possible to keep people occupied whilst they are waiting in reception. We must help them to stay calm. Here are some pointers to help reduce the threat of violence and aggression in reception areas: 

Training:

Staff working in general practice should know that their safety comes first. They should not be in situations that make them feel unsafe. However, if they are, they need to know how to deal with them. Appropriate staff training is therefore crucial. You should assess the risks to staff members and analyse their training needs. In doing so it will be possible to gauge the sort of training they require according to their roles and ensure that this is appropriate to the degree of risk an individual employee faces.

Training should be up-to-date, relevant, purposeful, backed by evidence, given by experts and include scope for feedback. Ideally, GPs and their staff should receive the same training to ensure continuity. 

Communications:

Maintaining effective communication channels with staff and particularly those working in the community (e.g. home visit) is important. The communication needs of staff and the measures that can be taken to minimise any risk to their safety need to be considered.

These might include:

  • Providing panic-button alarms and appropriate two-way communications systems such as mobile phones, which are increasingly being used by staff whose work places them in vulnerable situations. • Establishing protocols for informing members of staff that a colleague is out, where they have gone and their approximate return time. Procedures for reacting to protocols should also be in place.
  • Improving communications between all members of the practice team, keeping others abreast of potentially problem patients.

Avoiding Confrontation:

Avoiding confrontational situations involves a three-point plan; prevention, controlling the situation and de-escalating the situation. These are discussed in more detail below:

Prevention – there are several danger signals, which could include behaviour of others, your own behaviour, workplace or situational indicators. Staff should remain vigilant, think defensively and respond immediately to danger signals. 

Control – it is important to ensure you stay in control of a situation. Make sure you breathe deeply, maintain a barrier, stand side on, use open hand gestures and maintain eye contact. 

De-escalation – this can vary with the particular situation or individual concerned but strategies could include, acknowledging the aggressor’s mood, offering help, asking open ended questions, trying to resolve the problem, withdrawing or summoning assistance.

What to do if Prevention Fails:

Practices should work fully with the police in the event of an act of physical violence and for charges to be pressed. NHS England / the ICB should be notified immediately of any incident of violence or threat of violence which occurs on a practice premises or on a home visit. Treat any incidents of violence and aggression as a serious untoward incident and report it through the SUI reporting system.

What about Victims?

If there is a violent incident involving your workforce you will need to respond quickly to avoid any long-term distress to employees. It is essential to plan how you are going to provide them with support, before any incident. Depending on the extent of the incident you may wish to consider the following: 

Debriefing – victims (and witnesses) will need to talk through the experience as soon as possible after the event. Remember that verbal abuse can be just as upsetting as a physical attack. 

Time off work – individuals will react differently and may need differing amounts of time to recover. In some circumstances they might need specialist counselling. 

Legal help – in serious cases legal help may be appropriate. 

Other employees – may need guidance and/or training to help them to react appropriately.

The following security checklist provides a quick summary of the information contained within this guidance:

  • Enforce all security regulations in your practice
  • Know all security responsibilities and procedures
  • Inform others of security procedures
  • Stay alert and assertive
  • Avoid security short cuts
  • Always keep valuables out of sight
  • Mark all property with the practice postcode
  • Know what to do in an emergency
  • Always act within legal guidelines
  • Report suspicious incidents immediately
  • Use your security facilities to the full
  • Ask your local police Architectural Liaison Officer for advice

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Protocol for Premises Security

 This protocol is intended to provide practical suggestions on how to work to improve the safety and security of the physical environment from which you operate. It covers areas of best practice that can help to reduce the likelihood of aggressive behaviour and lists the minimum specification of security measures in terms of equipment that should be placed to protect staff, patients and visitors to the practice. 

  • Reception/Waiting areas should be kept clean and hospitable. Up to date reading material should be provided as a form of entertainment to reduce boredom, frustration and anxiety.
  • Space should be properly planned to avoid overcrowding and facilitate the movement of people.
  • Temperature should be controlled during seasonal extremes to maintain an environment that is comfortable.
  • Comfortable and appropriate seating should be provided i.e. suitable for people with disabilities also. Seating should be secured to the floor if the layout and use of the area allows.
  • Signs should be clear, simple and visible to direct people to the appropriate location e.g. treatment rooms, toilets.
  • Where artificial lighting is used, ensure that this is adequate and maintained to avoid flickering and failure.
  • Car parks and external concealed areas should be adequately lit using either automatic or activated lighting.
  • Access to the premises should be controlled and monitored. Consider the use of a single entrance/exit where possible.
  • Use high quality secure lockable doors where patient/visitor access is restricted.
  • Implement a routine for locking/unlocking the premises at the beginning and the end of the day. Two people should be present.
  • Reception desks should be wide enough to prevent potential aggressive patients reaching over.
  • More than one receptionist should be available at the front desk to allow a patient to be taken to one side if felt necessary, or so that a senior member of staff can be summoned without leaving reception unmanned.
  • Keep patients informed of any delays to reduce frustration.
  • Panic Alarms should be fitted in the reception area and all consulting rooms, out of the reach of children but easily accessible. Regular testing of the panic buttons and the planned response time is essential.
  • A dedicated phone line or posting messages on the computer should be used to communicate quickly and discreetly between the reception area and consulting rooms.
  • Chairs in consulting/treatment rooms should be sited closest to the door for easy escape from a potentially aggressive situation.
  • Mobile phones should be provided for staff working outside the practice environment and a “call in” system implemented.
  • Installation of CCTV should be considered obtaining specialist advice from a reputable security company.
  • Develop relations with your local police and crime prevention officer to provide ongoing support and advice.

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Be Prepared!   Some useful hints on personal safety

 Staying safe is very much a matter of common sense. The unfortunate thing is however, that when we feel threatened or vulnerable, common sense is something we tend to forget. Naturally, our safety depends very much on the actions of others, but by following some simple guidelines we can reduce the risk of attack and help to ensure our own safety and wellbeing.

Many GPs and their staff work predictable hours. This often entails traveling home later at night or early in the morning when public transport is not widely available. The following guidelines can apply to anyone in any situation. Think how much more relevant they are to you and when your working hours make you so much more vulnerable.

Walking:

  • Keep to main, well-lit paths and don’t take lifts from strangers. Carry a personal alarm. Walk facing the traffic.
  • Think about your clothing, wear something sensible that doesn’t attract attention and don’t wear shoes that may make it difficult to escape a difficult situation.
  • If attacked shout and scream, make as much noise as possible.
  • Be aware of your surroundings especially at cash points, telephone booths, near pubs and clubs.
  • Tell someone where you are going, which route you are taking and when you expect to be back.
  • Don’t carry large amounts of money and hide valuables from view. 

In the Car:

  • Keep your vehicle in good mechanical order and make sure that you always have sufficient petrol.
  • Know your route and always have a map handy. Park in a well-lit, easily visible area.
  • Ask someone to walk you to your car.
  • Lock all of your doors when driving along and keep personal belongings out of sight, NOT on the car seat next to you.
  • If you breakdown at night think before you act:
  • Are you safe inside the car?
  • Is the car in a dangerous position?
  • Are you in a well-lit residential area where you can call for help?
  • Is it likely that a police patrol vehicle will be close by?

Choose the option which involves least risk and report any suspicious behaviour or incidents immediately. 

In the Surgery:

There should be a system ready so that we know how to deal with attacks if they happen. If you are new to a surgery (e.g. locum) ask what the system is:

  • Develop a way of calling for help: an alarm code, bell push etc.
  • Call for help (and the police, if necessary) in plenty of time.
  • Write a full report on the incident.

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Violence Against Staff

 In the NHS violence against staff is an outward sign of frustration felt by many patients in our care. Fortunately, most people are able to control their emotions, but GPs and their staff are more likely than most to come across those who can’t. Here are some guidelines concerning violent patients and how to cope with them:

  • Look for signs of aggression such as uneven speech, shaking, changes in complexion and breathing.
  • Stay cool, think as a healthcare professional.
  • Immediately assess any dangerous situation. Think:
    • What has happened?
    • What might happen?
    • Is the person a danger to others?
    • Is the person a danger to themselves?
    • What was the cause of the situation?
  • If you can deal with the situation yourself do so, if not, get help by pushing an emergency button, calling for help, getting someone to take a message to a colleague.
  • Protect other patients and yourself.
  • Remember, damaged equipment is better than injured people.
  • Be positive, tactful, serious and assertive.
  • Don’t be confrontational or patronizing.
  • Try to reduce the tension and remove the cause of aggression.

Threats to staff on home visits: 

No matter how good security is in the practice, there will be times when a GP has to go out and visit patients in their own homes. Naturally, it is vital that we take all possible precautions to ensure that GPs are safe all of the time. Here are some practical tips that will help to reduce the risks faced by GPs on home visits:

  • Leave details of your itinerary at the practice and advise colleagues of any changes.
  • Carry a mobile phone so that you can advise colleagues of your whereabouts at regular intervals.
  • Arrange a code word/phrase that will alert your colleagues that you are in danger.
  • Lock all equipment in the boot of your car.
  • Keep comprehensive records of all home visits detailing any particular risks.

By keeping an up-to-date centralized record system, you will be aware of any potential problems before you visit the patient. Record details such as:

  • Location of property, is it remote?
  • Means of access to property.
  • Attitude of patient.
  • Any dangerous pets or obstacles?
  • Procedural problems, does patient find it difficult to move?

These records will act as an aide-memoir for next time you visit the property and an invaluable source of information for anyone else visiting the property for the first time.  Once you have assessed the risk in visiting a client, you can decide whether or not you need to be accompanied on your visit.

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If there is an Incident of Violence

You should report the incident to the police immediately. Don’t be afraid to report the incident. Your case will be treated sympathetically and in confidence. In serious cases, police forces have access to specially trained staff who will be able to give you the advice and counselling you need. Ask the operator for an incident number and make a note of it. 

Whilst you are waiting to speak to the police: 

Write down all the facts that you can remember about the attack, including:

  • How you felt
  • Details of any witnesses
  • Details of any injuries
  • Details of any weapons used
  • Details of any property damaged or stolen
    • Description of person involved (sex, height, age, build, clothing, facial features, ethnicity, hair colour, name if known)
    • Description of vehicle (make, colour, registration, number of occupants)
    • When the police attend, ask officer(s) attending for their collar number(s).

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Protecting Yourself Online

GPs and their staff are increasingly facing abuse from patients on social media. It is as unacceptable to abuse practices online as it is face-to-face, so you must understand how to protect yourself.

The BMA has published  a toolkit  for GPs, which covers:

  • practical steps to deal with online abuse and harassment
  • how to report abuse to social media platform providers
  • guidance on refusing to treat abusive patients
  • how and when to involve the police.

Doctors may also wish to access the BMA’s wellbeing services.

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Abuse is Not in a Day’s Work

The majority of people who need support from GP Practices do so in a respectful way that helps create a safe environment for all. Sadly, there are a very small number of people who can be abusive and aggressive to both staff and other patients. To help support your practice in a zero tolerance approach we have produced the below images which you can print as posters, use on your website or circulate via your social media channels. With thanks to Leeds ICB. #NotInADaysWork

Word Document Version of Images

 

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Last Reviewed Date
08/12/2023