Recurring concern

Failure to provide timely clinical follow-up after medication prescribing

First to latest report 14 Aug 2013 — 6 Jan 2026

Reports that mention this concern
21
Times this concern has been raised
23
Stated actions linked to this concern
35

What this concern includes

Includes timely clinical review after prescribing, assessment of treatment response, adherence or collection monitoring, and escalation when follow-up identifies concern.

What is not included
  • Unsafe prescribing, dispensing or administration where no follow-up deficiency is identified
  • Generic appointment failures unrelated to prescribed medication
  • Medication-specific toxicity or blood-level monitoring governed by a narrower dedicated control

Reports and published responses 21 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Dorset

    AI-generated summary

    JORDAN ANTHONY BUCKTON · 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

    JORDAN ANTHONY BUCKTON, aged 20, was found hanging by a ligature in his cell at HMYOI Portland on 28 January 2012. Concerns included failures to share information about his previous self-harm, to follow up after antidepressant medication was prescribed, and to continue an Emotional Wellbeing course after staff absence.

    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 complete PHQ9 assessments after antidepressant prescribing

    Wider context from the report

    “(2) Follow Up After Issue of Anti-Depressant Medication On the 6th December 2011 one of the attending GP’s ████████ prescribed Fluoxetine to Mr Buckton on the recommendation of Healthcare Assistant Board who stated that she had discussed such prescription with the Mental Health Team and felt that Mr Buckton was depressed. ████████ did not see Mr Buckton nor did she see him after that date to check the effectiveness of the medication. The jury found there was a failure by Healthcare staff to follow up Mr Buckton’s appointment with the GP and a failure to complete a PHQ9 Assessment. If there had been a follow up appointment with Mr Buckton at the end of January 2012 it may be that raised risk of suicide would have been spotted and treated. The expert witness ████████ was critical of this failure. He gave evidence that a follow up appointment is recommended in the Quality and Outcomes Framework Guidance to GP’s but is also a requirement of the National Institute of Clinical Excellence Guideline 90 which recommends “For people stated on anti-depressants who are not considered to be at increased risk of suicide, normally see them after 2 weeks. See them regularly thereafter for example at intervals of 2-4 weeks in the first 3 months and then at longer intervals if the response is good. Early cessation of treatment is associated with a greater risk of relapse”. ”

    Source location

    JORDAN ANTHONY BUCKTON · Prevention of Future Deaths report
    Page 2 · concerns

    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 to provide timely follow-up after antidepressant prescribing

    Wider context from the report

    “(2) Follow Up After Issue of Anti-Depressant Medication On the 6th December 2011 one of the attending GP’s ████████ prescribed Fluoxetine to Mr Buckton on the recommendation of Healthcare Assistant Board who stated that she had discussed such prescription with the Mental Health Team and felt that Mr Buckton was depressed. ████████ did not see Mr Buckton nor did she see him after that date to check the effectiveness of the medication. The jury found there was a failure by Healthcare staff to follow up Mr Buckton’s appointment with the GP and a failure to complete a PHQ9 Assessment. If there had been a follow up appointment with Mr Buckton at the end of January 2012 it may be that raised risk of suicide would have been spotted and treated. The expert witness ████████ was critical of this failure. He gave evidence that a follow up appointment is recommended in the Quality and Outcomes Framework Guidance to GP’s but is also a requirement of the National Institute of Clinical Excellence Guideline 90 which recommends “For people stated on anti-depressants who are not considered to be at increased risk of suicide, normally see them after 2 weeks. See them regularly thereafter for example at intervals of 2-4 weeks in the first 3 months and then at longer intervals if the response is good. Early cessation of treatment is associated with a greater risk of relapse”. ”

    Source location

    JORDAN ANTHONY BUCKTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026