16 May 2019 Natasha Elizabeth Victoria Abrahart · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1
Failure to arrange timely follow-up review after starting antidepressants for people at increased suicide risk or younger than 30 years View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Natasha Elizabeth Victoria Abrahart · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Natasha Elizabeth Victoria Abrahart died on 30 April 2018 after placing a ligature around her neck. She was under the care of a mental health team that had not provided a timely and detailed management plan following several assessments. The report also identifies concerns that follow-up after starting sertraline, including review of suicide risk, did not comply with the cited NICE guideline; the inquest concluded that the death was suicide contributed to by neglect.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to arrange timely follow-up review after starting antidepressants for people at increased suicide risk or younger than 30 years
Wider context from the report “The NICE guideline Depression in Adults: Recognition and management (CG90) states in section 1.5.2.7 “A person with depression started on antidepressants who is considered to present an increased suicide risk or is younger than 30 years (because of the potential increased prevalence of suicidal thoughts in the early stages of antidepressant treatment for this group) should normally be seen after 1 week and frequently thereafter as appropriate until the risk is no longer considered clinically important ”
In this case Sertraline was prescribed but the NICE guideline was not followed by the mental health trust or the GP practice.
The expert indicated that the review at 1 week is to ensure that the patient is taking the medication, to check for any side effects including suicide risk and to see what has happened ; that review can be done by the G.P. or the mental health team but there needs to be a known appointment.
” Source location Natasha Elizabeth Victoria Abrahart · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add an SSRI and suicidality prompt to the first mental health assessment template.
Verbatim wording from the response “Following the inquest touching upon NA’s death, we have added an additional field on our first mental health assessment template regarding SSRI and suicidality: “If SSRI newly prescribed: counsel re side effects and risk increase suicidality; when is follow up?”” Source location 2019-0504-Response-from-University-of-Bristol_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Schedule routine reviews one week after starting an SSRI, with booked or known follow-up appointments and appropriate follow-up after cancellations or non-attendance.
Verbatim wording from the response “In response to the concerns expressed within your Regulation 28 report, we have moved appointments to review patients when starting an SSRI routinely to 1 week, if this is manageable for the patient, and have this as a ‘booked’ or ‘known’ appointment in accordance with NICE guidance.” Source location 2019-0504-Response-from-University-of-Bristol_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit a permanent mental health nurse, define a role reviewing higher-risk or SSRI-starting patients at seven days, and plan use of the new resource with local partners.
Verbatim wording from the response “Since the inquest we have requested additional funding from the University to advertise for a permanent Mental Health Nurse to join our team and this has been agreed. We are currently working on an advert and job description. The job plan for this member of the team would include reviewing patients under 30 thought to be at risk of suicide, or starting on SSRI, at 7 days. We are liaising with local partners, mental health advisory service and psychology team to plan how best to utilise this new resource.” Source location 2019-0504-Response-from-University-of-Bristol_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Distribute a Trust-wide alert requiring adherence to NICE antidepressant-prescribing guidance, documented seven-day review responsibility, and auditable team responses.
Verbatim wording from the response “We have distributed a Red Top Alert via our Trust-wide alerting system instructing all medical personnel, all non-medical prescribers, all pharmacists and all team managers to be ensure that prescribers follow the NICE Guidance in relation to the prescribing of anti-depressants (CG90). The instruction includes a requirement to adhere to the guidance and makes clear the responsibility to communicate effectively with primary care about which individual will undertake the review at seven days; and that this must be clearly documented. There is a robust auditable system which demands a response from all the teams circulated in the alert, permitting the identification of any gaps. There will be an obligation for medical leads to discuss this with all their line reports, to ensure effective communication of this alert.” Source location 2019-0504-Response-from-AWP
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require medical leads to discuss the prescribing alert with all line reports to reinforce effective communication.
Verbatim wording from the response “We have distributed a Red Top Alert via our Trust-wide alerting system instructing all medical personnel, all non-medical prescribers, all pharmacists and all team managers to be ensure that prescribers follow the NICE Guidance in relation to the prescribing of anti-depressants (CG90). The instruction includes a requirement to adhere to the guidance and makes clear the responsibility to communicate effectively with primary care about which individual will undertake the review at seven days; and that this must be clearly documented. There is a robust auditable system which demands a response from all the teams circulated in the alert, permitting the identification of any gaps. There will be an obligation for medical leads to discuss this with all their line reports, to ensure effective communication of this alert.” Source location 2019-0504-Response-from-AWP
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Changing QOF depression review criteria requires national-level action, with feedback routed through the local CCG.
Verbatim wording from the response “The current QOF (Quality Outcomes Framework) for depression states that a depression interim review should be undertaken at 10-56 days. Having reviewed the guidance around treatment of depression we would suggest that changing the achievement criteria within this QOF domain is a potential area for positive change. A change to this time frame might improve mental health outcomes across primary care, if it were updated at national level to reflect best practice. We intend to feed this back to our local CCG in the near future.” Source location 2019-0504-Response-from-University-of-Bristol_Redacted
Open published response
26 Jul 2018 Daniel Young · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1
Failure of GP surgeries to routinely monitor psychiatric patients’ collection of antipsychotic medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel Young · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Young, a fit and healthy university lecturer, was randomly attacked on his way to work on 19 January 2016 and sustained a fatal stab wound to the abdomen. The report raised concerns that GP surgeries did not routinely monitor whether psychiatric patients collected their antipsychotic medication, despite the risk that stopping treatment could lead to relapse and harm to others.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of GP surgeries to routinely monitor psychiatric patients’ collection of antipsychotic medication
Wider context from the report “2. GP surgeries do not routinely monitor that psychiatric patients are collecting their antipsychotics . Evidence revealed that it is not uncommon for such patients to stop their medication and relapse. Relapse puts them at a risk of harm to themselves and, sometimes, they pose a risk to others.
” Source location Daniel Young · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to GP practices about monitoring collection of antipsychotic medication prescriptions.
Verbatim wording from the response “In the interim, NHS England has confirmed that it will undertake the following actions by the end of the year to address the issues noted in your report:” Source location 2018-0240-Response-by-Department-of-Health-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ask GP practices to consider mechanisms for monitoring collection of antipsychotic medication prescriptions.
Verbatim wording from the response “• NHS England will write to GP practices to make them aware of this issue and to consider what mechanism they do or could employ to monitor the collection of antipsychotic medication prescriptions;” Source location 2018-0240-Response-by-Department-of-Health-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore with NHS Digital opportunities for primary care systems to alert GPs about prescription collection issues for named patients and drugs.
Verbatim wording from the response “• NHS England will explore with NHS Digital what opportunities there are for primary care clinical systems to alert GPs around prescription collection issues for named patients and named drugs; and” Source location 2018-0240-Response-by-Department-of-Health-Social-Care
Open published response
17 Nov 2017 Paul Geoffrey Mullen · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2
Failure to report prescribed medication non-collection directly to the designated Key Worker View source Failure of the medication non-collection reporting threshold to identify concerns after one or two missed daily collections for reliably compliant patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Geoffrey Mullen · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Geoffrey Mullen died at his home in Wigan on 22 June 2017. He had been receiving daily methadone but did not collect it for three consecutive days before his death. The report raised concerns that the pharmacy’s failure to report the missed collections promptly to his designated Key Worker, and the three-day reporting threshold, may have delayed checks on his welfare.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to report prescribed medication non-collection directly to the designated Key Worker
Wider context from the report “1. During the Inquest evidence was heard that:-
i. The deceased was receiving a daily prescription of methadone to be collected and administered on a daily basis from the Pharmacy. The prescriptions were not collected from the Pharmacy on Monday the 18th June 2017, Tuesday the 19th June 2017 and Wednesday the 20th June 2017.
ii. There is a system, referred to at the Inquest as a “red flag system”, for a pharmacy to report the non-collection of a prescription of methadone when a patient has not collected the medication on three consecutive occasions. The evidence at the Inquest indicated that the purpose of the report by a pharmacy of non-collection is to enable the Key Worker to be made aware of the non-collection of the medication so that the Key Worker could take appropriate action to contact the patient and to check whether any concerns need to be addressed.
iii. The Key Worker attached to the deceased was ████████, who is a Key Worker employed by Addiction, and she gave evidence that the procedure relating to the deceased, and other patients, to report non-collection of medication is for the report to be sent by a pharmacy to GMMH and not directly to the Key Worker . In the case of the deceased, ████████, the deceased’s Key Worker, did not receive a report that the deceased had not collected his methadone on the above dates and she only became aware of his non-collection of methadone by her own enquiry when she telephoned the Pharmacy to request that the prescription of methadone be placed on hold.
iv. ████████ also gave evidence that some patients, particularly those patients who are known to be diligent and to collect their medication on time each and every day, may require a report of non-collection of medication earlier than three days because, in relation to those patients, a single failure to collect medication may raise concerns and require enquiries by the Key Worker as to any concerns, in view of the fact that those patients always collect their medication each and every day.
v. GMMH is a Mental Health NHS Foundation Trust and is separate in terms of governance, even though working in partnership to an extent, from Addiction, which is described as a Drug, Alcohol and Mental Health Treatment Charity. Accordingly, any report relating to the non-collection of medication addressed to GMMH requires a further onward report from GMMH to Addiction . The governance of GMMH has no control over Practitioners employed by Addiction and GMMH and Addiction do not share computer reporting systems.
” Source location Paul Geoffrey Mullen · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the medication non-collection reporting threshold to identify concerns after one or two missed daily collections for reliably compliant patients
Wider context from the report “1. During the Inquest evidence was heard that:-
i. The deceased was receiving a daily prescription of methadone to be collected and administered on a daily basis from the Pharmacy. The prescriptions were not collected from the Pharmacy on Monday the 18th June 2017, Tuesday the 19th June 2017 and Wednesday the 20th June 2017.
ii. There is a system, referred to at the Inquest as a “red flag system”, for a pharmacy to report the non-collection of a prescription of methadone when a patient has not collected the medication on three consecutive occasions . The evidence at the Inquest indicated that the purpose of the report by a pharmacy of non-collection is to enable the Key Worker to be made aware of the non-collection of the medication so that the Key Worker could take appropriate action to contact the patient and to check whether any concerns need to be addressed.
iii. The Key Worker attached to the deceased was ████████, who is a Key Worker employed by Addiction, and she gave evidence that the procedure relating to the deceased, and other patients, to report non-collection of medication is for the report to be sent by a pharmacy to GMMH and not directly to the Key Worker. In the case of the deceased, ████████, the deceased’s Key Worker, did not receive a report that the deceased had not collected his methadone on the above dates and she only became aware of his non-collection of methadone by her own enquiry when she telephoned the Pharmacy to request that the prescription of methadone be placed on hold.
iv. ████████ also gave evidence that some patients, particularly those patients who are known to be diligent and to collect their medication on time each and every day, may require a report of non-collection of medication earlier than three days because, in relation to those patients, a single failure to collect medication may raise concerns and require enquiries by the Key Worker as to any concerns, in view of the fact that those patients always collect their medication each and every day.
v. GMMH is a Mental Health NHS Foundation Trust and is separate in terms of governance, even though working in partnership to an extent, from Addiction, which is described as a Drug, Alcohol and Mental Health Treatment Charity. Accordingly, any report relating to the non-collection of medication addressed to GMMH requires a further onward report from GMMH to Addiction. The governance of GMMH has no control over Practitioners employed by Addiction and GMMH and Addiction do not share computer reporting systems.
” Source location Paul Geoffrey Mullen · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement website-based reporting of each missed supervised methadone or buprenorphine dose.
Verbatim wording from the response “From the 1st of April 2018 Addaction took over the management of Wigan’s supervised methadone/buprenorphine program. The new system allows each pharmacy providing a supervised methadone/buprenorphine service, the ability to notify each time of each missed dose via a pharmaceutical website. The Pharm Outcomes website has a one, two and three day missed dose option but we will also continue to manually ring the clients key worker directly when a client has missed 3 days.” Source location 2017-0403-Responses
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train all pharmacy staff and locums to use the missed-dose reporting system.
Verbatim wording from the response “All staff and locums have been trained on the system.” Source location 2017-0403-Responses
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add the client’s key worker name to every blue supervised prescription.
Verbatim wording from the response “All blue supervised prescriptions will state the clients key worker name to assist in efficient reporting.” Source location 2017-0403-Responses
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review missed-medication reporting systems and concerns about the three-day rule.
Verbatim wording from the response “The Senior Management Team in GMMH within the Wigan and Leigh Recovery Partnership (WLRP – which is a partnership between GMMH and Addaction) have undertaken a review into the concerns you have raised. To assist you I have provided the Trust response below each of the highlighted concerns.” Source location 2017-0403-Responses
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The established three-day rule is considered sufficient and should continue as the consistent safety process for missed medication collection.
Verbatim wording from the response “It would be unwise for community pharmacy to advise GMMH each and every time a patient missed a dispense. The situation is, in the GMMH Orange Book, that three days is the critical period in which tolerance to opiates may begin to be lost, and it is best practice in terms of safety that, in that sense, all parties best promote safety by consistently following the three day rule.” Source location 2017-0403-Responses
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The “red flag system” was not an established system within GMMH or the Wigan and Leigh Recovery Partnership.
Verbatim wording from the response “As you are aware representatives from GMMH were not requested to attend Mr Mullen’s inquest. Following the review of your concerns I am aware that the Addaction worker providing evidence at the inquest has used the term red flag system. However, this is not a term that has been used as a system by any of our Senior Management team at GMMH or within the WLRP. There is a clinical principle (known colloquially as the three day rule) which is outlined in the UK Department of Health and UK guidelines on clinical management 2017 Update (often called the Orange Book). It is possible for a worker to have been advised across the UK clinicians and prescribers. The section 4.6.3 specifies that no further dispenses of drug dependence medication, consecutive doses have been missed, and community pharmacists are then advised to contact the prescribing service in this case would have been GMMH.” Source location 2017-0403-Responses
Open published response
20 Apr 2017 Charlotte Anne Agnew · Prevention of Future Deaths report City of London
View report summary
Concerns raised 1
Failure to provide means of monitoring psychiatric medication effectiveness View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Charlotte Anne Agnew · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Charlotte Anne Agnew became psychiatrically unwell and expressed suicidal ideation. After referrals to psychiatric services, her care was not effectively transferred, her suicide risk was not sufficiently assessed or managed, and no care plan was put in place; she died on 25 March 2016 after ingesting high levels of alcohol and medication and jumping in front of a London Underground train. The report identified an ongoing risk that similar failures in timely assessment, treatment, care transfer and suicide-risk management could recur.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide means of monitoring psychiatric medication effectiveness
Wider context from the report “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were:
(1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case. A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge.
(2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide. Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide.
(3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge.
(4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness .
(5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016.
I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance.
Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise).
Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary. Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised.
In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives.
” Source location Charlotte Anne Agnew · Prevention of Future Deaths report
Open source report
6 Aug 2015 THOMAS THEO CHARLES THURLING · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Failure to provide timely and continuous monitoring following medication changes View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
THOMAS THEO CHARLES THURLING · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Theo Charles Thurling, who had increasing depression, anxiety and suicidal ideation, was found dead at home on 28 October 2014 after he did not respond to visits. The inquest concluded that he took his own life, with medical cause of death recorded as asphyxiation. Concerns included medication changes not being adequately monitored, a prolonged absence of his Care Co-ordinator without alternative cover or review, and staff shortages.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide timely and continuous monitoring following medication changes
Wider context from the report “(1) On 13 August 2014 Mr Thurling's medication was changed to help his low mood and anxiety. The Psychiatrist specifically stated that the change in medication was to be monitored to include the involvement of the CRHT Team . One Psychiatrist gave evidence (which was read) that the change in medication was closely monitored by Mind. Mr Thurling later declined any input from the CRHT Team. His Care Co-Ordinator was unaware of the symptoms to look for. Despite close involvement, Mr Thurling's family were unaware of the change in medication and the request for monitoring.
Although Mr Thurling was seen daily by Mind they were unaware of any change in medication and the request for monitoring.
An Out Patient Review was not arranged until 6 weeks later .
Following that Out Patient Review the Care Co-Ordinator was absent from work on planned and unplanned leave. Nothing was put in place for monitoring the medication .
” Source location THOMAS THEO CHARLES THURLING · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share medication-change monitoring concerns with Pharmacy, Triangle of Care leads and clinical teams for learning to be cascaded.
Verbatim wording from the response “In considering the means by which to ensure this practice is consistent, no single action will provide assurance. Recognising the task involves technical knowledge of medication and an understanding of the need to communication to the wider group of people involved in supporting the service user, we are sharing the issue with a range of leads in specific areas, such as the Pharmacy and those leading the implementation of Triangle of Care, as well as clinical teams. They will use this direction to cascade learning.” Source location 2015-0309-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise medication-change monitoring directly with clinical staff through internal communications and clinical forums.
Verbatim wording from the response “Further, the matter will be raised directly with clinical staff via internal communications and clinical forums.” Source location 2015-0309-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
29 Apr 2015 Jorge Emanuel Mousinho Assabay E Castro · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure to review patients’ non-collection of prescribed medication View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jorge Emanuel Mousinho Assabay E Castro · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jorge Emanuel Mousinho Assabay E Castro died at home on 16 October 2014 after being found collapsed and unresponsive. He had post-traumatic epilepsy but had not received sodium valproate after 3 July 2014, despite attending his GP practice three times without the medication issue being reviewed. The principal concerns were the lack of systems to identify uncollected prescriptions and to alert GPs to medication-adherence concerns, particularly for vulnerable patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to review patients’ non-collection of prescribed medication
Wider context from the report “1. During the Inquest evidence was heard that:
i. Jorge had not received sodium valproate medication for administration after 3rd July 2014 and he had been diagnosed with post traumatic epilepsy in February 2014 requiring regular treatment with sodium valproate as an anti-epileptic medication.
ii. Jorge had been seen by General Practitioners at the Springfield Medical Centre on three occasions after the 3rd July 2014 without any review of the fact that he had not collected prescriptions for sodium valproate and the fact that the General Practitioner had received a letter from ████████ alerting the General Practitioner to an issue in relation to his regular adherence with his anti-epileptic medication.
iii. Jorge was known to be a vulnerable person, who consumed excess amounts of alcohol on a regular basis and who was being treated with Citalopram for depression prior to his injuries on the 20th June 2013 and subsequently on the 18th September 2014 prior to his death.
iv. The General Practitioner’s surgery at Springfield Medical Centre does not appear to have any systems to identify and highlight a patient who has not collected prescriptions, particularly in relation to vulnerable patients who will be dependent on medication for the control of a diagnosed condition and, as in the case of Jorge, to reduce the risk of episodes of seizure.
In particular the computerised records do not have a system of highlighting any outstanding prescriptions at subsequent consultations so that a General Practitioner was not alerted to the fact that Jorge had not collected his prescriptions and would not have had a supply of his anti-epileptic medication after the 3rd July 2014 at any of the appointments following the 3rd July 2014.
v. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues.
2. I request you to consider the above concerns, particularly with regard to the following:
i. The procedures and systems to highlight and alert General Practitioners in relation to concerns or issues raised by a Hospital Consultant, namely in Jorge’s case by ████████ with regard to Jorge’s regular adherence with his anti-epileptic medication.
ii. A review of your systems and procedures to alert General Practitioners in relation to the issue of prescriptions and the failure of a patient to collect prescriptions for prescribed medications, particularly in relation to vulnerable patients who have not collected or received their prescriptions for a period of time.
iii. Training of all staff, both professional and administrative, in relation to record keeping and checks in relation to outstanding prescriptions, particularly when a vulnerable patient has not collected a prescription and has not received necessary and prescribed medications for a period of time.
” Source location Jorge Emanuel Mousinho Assabay E Castro · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement patient-record alerts when medication-compliance concerns are raised, with staff notifying management so alerts are activated.
Verbatim wording from the response “medication. As a practice we have considered how our IT system can support the practice team in alerting us to similar issues with patients. It is possible for an alert to flag up when any member of staff enters the patient’s records and this will now be implemented for any patients who, similar to Mr Castro, are known to have compliance issues with their medication. All practice staff, clinical and administrative, have been advised to inform the practice management team immediately of any patient where compliance issues have been raised by family, carers or any other health care professionals. The management team will then ensure that an alert is activated on the patient’s records.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the prescribing system to highlight overdue prescriptions after three months and prompt timely clinical follow-up.
Verbatim wording from the response “time period and the practice has made the necessary amendments so that in future any staff viewing a patient’s prescriptions will be alerted sooner (from 3 months) and appropriate action can be taken to mitigate any risk to the patient. This would include immediate notification to the General Practitioner who would then liaise with the patient, carers, family and pharmacy as appropriate. The practice can then work with all necessary individuals or agencies to help support the patient with compliance of their medication.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and regularly update a register of patients receiving weekly prescriptions, with monthly administrative checks and GP review of omissions.
Verbatim wording from the response “However, even this system has its limitations, as it would only highlight the issue of overdue prescriptions when a member of the practice team is actually in the patient’s records and looking at the repeat medication screen. As a practice we have over 3000 patients on regular repeat medication. Each prescription is usually for 1 to 2 months duration. However, approximately 300 of these patients, like Mr Castro, are issued medications on a weekly basis. This system is usually for patient safety or as a compliance aid. We have thus decided to create a register of all patients who are receiving prescriptions on a weekly basis. These prescriptions are issued in 4 weekly batches and the administrative staff will be checking the prescriptions have been issued for each patient every month. Those that have not been issued will be passed to a General Practitioner for review.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Notify and collaborate with local pharmacies regarding interruptions to weekly medication collection or supply, and disseminate the significant-event learning.
Verbatim wording from the response “Weekly prescriptions are all sent to the patient’s nominated pharmacy. We have written to our local pharmacies and asked them to kindly inform us if there is any interruption to any of these patients’ medication collection or supply.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a half-day training workshop for staff involved in repeat-prescription generation to support the revised systems and procedures.
Verbatim wording from the response “3. Training of all staff in relation to prescribing
As a practice we have taken this opportunity to look at our prescribing systems and the changes above do require staff training. However, we have also looked at the possibility of external facilitators who may bring further advice and expertise to the practice of effective management of repeat prescribing. We can confirm that a half-day workshop has been arranged for Thursday 25th June and we would be open to any further recommendations on this day.” Source location 2015-0170-Response-by-Springfield-Medical-Centre
Open published response
Concerns raised 1
Lack of a computer-driven system to flag prescription non-attendance View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Jason Edward Lawson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jason Edward Lawson, who had epilepsy and schizophrenia, was found dead in his prison cell at HMP Stocken on 17 March 2013; the time of death was uncertain but likely late on 16 March or early on 17 March. Concerns included welfare checks that did not establish that he had died, systems that did not reliably identify medication non-attendance or lapsed prescriptions, access delays to healthcare, and the absence of a specific policy for 24-hour medical observation where constant medical supervision was unavailable.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a computer-driven system to flag prescription non-attendance
Wider context from the report “3. The current system relies on healthcare staff/pharmacy staff recognising that prisoners have not attended to collect their prescription , without having a computer driven system to flag up non-attendance .
” Source location Jason Edward Lawson · Prevention of Future Deaths report
Open source report
6 Jan 2015 John Ioannou · Prevention of Future Deaths report North London
View report summary
Concerns raised 1
Lack of guidance for GPs when patients are not collecting medication required to treat their mental health conditions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Ioannou · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 4 April 2014, John Ioannou fatally injured himself after jumping from a window at his home. The report identified a concern that there was no guidance for GPs when a patient was not collecting medication required to treat a mental health condition, and that this information was not available to the Mental Health Team.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of guidance for GPs when patients are not collecting medication required to treat their mental health conditions
Wider context from the report “There was no guidance for GPs where the patient is not collecting medication required to treat their mental health condition (s).
” Source location John Ioannou · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NICE guidance addresses poor adherence by requiring re-referral to secondary care and development of shared risk management plans.
Verbatim wording from the response “The National Institute for Health and Clinical Excellence (NICE) has published guidelines which set out best practice for the treatment of Bipolar Disorder. This includes guidance that where a patient is being treated solely in a primary care setting (e.g. by a GP) the patient should be re-referred to secondary care if treatment adherence is poor. The guidelines also state that in managing crisis, risk and challenging behaviour in adults with Bipolar Disorder secondary care providers should develop a risk management plan and share it with the patient’s GP.” Source location 2015-0012-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitoring whether patients collect or take medication would be difficult because of scale, data-sharing, consent and treatment-refusal constraints.
Verbatim wording from the response “However, there is a larger question of how a GP would become aware that a patient had stopped taking medication, particularly if medication is prescribed on a repeat prescription which allows patients to order re-fills without seeing their GPs. Over one billion prescription items are issued by general practices each year and it would therefore be a large and complex task to monitor individual patients. Aside from the practicalities, there would be issues of appropriate data sharing, patient consent, and the right to refuse treatment. NHS England advises that it has sought the advice of its Primary Care Patient Safety Expert Group and Mental Health Patient Safety Expert Group on what action might feasibly be taken in this area. NHS England will be able to provide an update on these discussions by the end of April 2015.” Source location 2015-0012-Response-by-Department-of-Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for considering feasible action on monitoring medication non-collection and providing an update.
Verbatim wording from the response “However, there is a larger question of how a GP would become aware that a patient had stopped taking medication, particularly if medication is prescribed on a repeat prescription which allows patients to order re-fills without seeing their GPs. Over one billion prescription items are issued by general practices each year and it would therefore be a large and complex task to monitor individual patients. Aside from the practicalities, there would be issues of appropriate data sharing, patient consent, and the right to refuse treatment. NHS England advises that it has sought the advice of its Primary Care Patient Safety Expert Group and Mental Health Patient Safety Expert Group on what action might feasibly be taken in this area. NHS England will be able to provide an update on these discussions by the end of April 2015.” Source location 2015-0012-Response-by-Department-of-Health
Open published response
Concerns raised 1
Failure to address suspected non-compliance with lifelong anticoagulation View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Leslie Edmund Harding (Lez) · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Leslie Edmund Harding had a history of multiple sclerosis and recurrent pulmonary emboli, and died after collapsing on 28 September 2013. The report raised concerns about the lack of action after he was assessed with chest pain and suspected pulmonary embolus, gaps in anticoagulation prescribing and follow-up, insufficient efforts to address alleged non-compliance, and the absence of a prompt significant events review.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to address suspected non-compliance with lifelong anticoagulation
Wider context from the report “3. At Inquest, I gained the impression that Lez was felt to be non-compliant with his anti-coagulation regime. It was plain from the prescription history that there were repeated gaps in the provision of medication that Lez required. There seemed, however, in my view, to have been little effort given to addressing the reasons why, or indeed if, Lez actually was non-compliant with his medication. By way of illustration, I was not shown a letter from the Surgery to Lez bringing to his attention that he had failed to collect his monthly supply of Clexane and warning him of the risks of failing to maintain the treatment regime.
I heard evidence at Inquest that Lez could be an awkward patient. In my view, of itself, that is insufficient reason not to make every reasonable effort to ensure that a patient complies with an identified need for lifelong anti-coagulation .
” Source location Leslie Edmund Harding (Lez) · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review advice given when patients begin anticoagulation.
Verbatim wording from the response “3) As a result of this situation, I have reviewed the advice given to people when they first begin anti-coagulation and as a practice we are in the process of composing a letter informing people of the risks of non-concordance with medication.” Source location 2014-0169-Response-by-Oakside-Surgery
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Compose a letter informing patients of the risks of non-concordance with medication.
Verbatim wording from the response “3) As a result of this situation, I have reviewed the advice given to people when they first begin anti-coagulation and as a practice we are in the process of composing a letter informing people of the risks of non-concordance with medication.” Source location 2014-0169-Response-by-Oakside-Surgery
Open published response
Concerns raised 1
Failure to respond to medication non-collection with a home assessment View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Joan Farran · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joan Farran, who had multiple co-morbidities and was cared for by her adult son, died at home from bronchopneumonia due to chronic obstructive pulmonary disease and Alzheimer’s disease. The report states that her death from a potentially treatable pneumonia was contributed to by neglect in obtaining medical support and treatment. Concerns included inadequate coordination and information-sharing between agencies, limited assessment of the home environment, withdrawal of community visits without replacement services, and the cancellation of a GP home visit without further follow-up.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to respond to medication non-collection with a home assessment
Wider context from the report “7. All of these visits appear to have been conducted in the deceased' bedroom and no visits were made to any other part of the house and particularly the living room, dining room, kitchen and back yard. Significantly it is these areas which were found to be excessively cluttered during the investigation by the Police, subsequent to the deceased' death.
8. The Inquest received evidence from an Environmental Health Office who gave evidence that the clutter within the home was at least 8 months old but acknowledged that because this was a criminal investigation, he did not asitwere dig too deep into the material present to identify exact dates as to the packaging and other detritus which was present.
9. The Community Matron was himself unwell in the period March to July 2012 and subsequently from July ceased further visits. No other external services appear to have visited this home between July and December 2012 to determine how the deceased was progressing.
10. There were concerns expressed by the General Practice and in particular by the Pharmacy who were dispensing the deceased' repeat prescriptions that there were instances of non-collection of the medication and indeed a review was carried out late in that year as to the nature of the medication the deceased needed. There was no further visit at that stage to the deceased' home however.
11. Having received a communication from the deceased' son, on the 7th December as to his mother's state of health the Community Matron did make direct contact with the practice in order to try and ensure an appointment was made. He was nonetheless of a view that at that juncture there should in fact be some urgent and immediate visit but the matter was left on the basis only of a home visit to be made on the Monday 10th December.
12. That visit was cancelled and no further contact was made with the deceased or visit made to the home by the practice or any other outside agency.
13. Any visit that was made at that juncture or indeed at any earlier juncture which sought to visit more extensively within the home would have had clearly demonstrated that all was not well in the care and management of the deceased by the son and indeed that the son himself as a carer, was incapable of meeting the needs of his mother and himself was suffering from chronic problems, in all probability alcoholism.
14. The opinion of the NeuroPathologist who examined the deceased' body was of the opinion that the deceased was suffering from established dementia and that that should have been apparent to those who had her care. It was undiagnosed. If the deceased had received even the basic of treatment during the week immediately before her death, there is every reason to believe the deceased' death from a treatable condition would have been avoided.
15. My concern on this occasion is that although there were at least three agencies actively engaged in the care of this lady , or called to review her care during the months preceding her death, there has been a failure to co-ordinate information available to them.
16. There is evidence that they have failed to appreciate or investigate more robustly and objectively circumstances of the deceased' situation ,to be easily put off by the deceased' own presentation in the case of the visit by Social Services early in 2012, reassured that others had apparently raised no issue and in the event were continuing to visit , when ultimately they chose to withdraw those services very soon after.
17. The complaint the daughter should have at least led to an opportunity to examine the living accommodation more fully and more pointedly to maintain some contact into the future months and not to rely on the result and conclusion of one single visit and in any event to maintain a co-ordinated overview between the Community Matron Services, the GP and Social Services.
18. This incident occurring as it has at or about the same time as Elizabeth and Robert Douthwaite ( 17th January 2013) highlights the need for a robust and co-ordinate approach between the several agencies working within the Community who may come into contact with individually vulnerable individuals within the community. The active sharing of information and staged reviews are an essential element leading to co-ordinated care strategies.
” Source location Joan Farran · Prevention of Future Deaths report
Open source report
Pin
Get email alerts
Request correction
Includes timely clinical review after prescribing, assessment of treatment response, adherence or collection monitoring, and escalation when follow-up identifies concern.
