9 Sep 2024 Amanda Richardson · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure of hospital systems to review and safeguard medication prescribing and administration View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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Amanda Richardson · 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
Amanda Richardson, aged 40, was transferred from prison to a low secure mental health hospital and was found dead in her bedroom on 29 April 2023. Toxicology found a very high level of a prescribed drug, which had been prescribed at double the stipulated maximum dose, alongside evidence of illicit drug use. The concerns included inadequate medication review and monitoring, failures to record and investigate searches, and the adequacy of hospital security arrangements.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of hospital systems to review and safeguard medication prescribing and administration
Wider context from the report “2. It was admitted that the prescription of ████████ at the rate of ████████mg/day was double the ████████mg/day stipulated maximum (without additional monitoring being undertaken) and was made in error. This situation went unnoticed for some six months, until her death. There was no effective system of review in the hospital in this period. The pharmacist appears to have dispensed the drug without querying the high dose. The nurses who administered the drugs did not question it. The MDT meetings which took place did not check the dose, or reflect upon its potential interaction with the several other medications prescribed. Overall, there was no effective resilience in the hospital’s systems to safeguard against drugs bring prescribed or administered in error .
” Source location Amanda Richardson · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Actions taken following the Serious Incident Report are considered sufficient to address identified issues and prevent similar future deaths.
Verbatim wording from the response “Inmind Healthcare remain committed to learning and improving service but given the assurances given to the Coroner at the Inquest, Inmind Healthcare consider that actions have been taken to fully address the issues identified by the Serious Incident Report and to prevent future deaths in similar circumstances.” Source location Response from InMind
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Concerns raised 1
Unavailability of practice warning flags at the three-month stage of morphine prescribing View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Louise Helen Jones · 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
Louise Helen Jones was found deceased at home on 1 October 2023. The inquest recorded respiratory depression and opiate drug use, following an unintentional overdose involving morphine and bromazalam alongside other central nervous system depressant drugs. Concerns included the absence of an agreed opioid treatment and end-of-treatment plan, practice policies for long-term opioid prescribing and opioid–benzodiazepine co-prescribing, and warning flags after three months of morphine prescription.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of practice warning flags at the three-month stage of morphine prescribing
Wider context from the report “(3) There were no warning flags in place at the practice at the 3-month stage of morphine prescription , to reflect the MHRA/CHM advice referred to in NICE guidance, regarding the increased risk of addiction beyond this period.
” Source location Louise Helen Jones · Prevention of Future Deaths report
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4 Mar 2024 Mr Lee Martin Hughes, also known as Martin Lee Hughes · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Failure to account for reduced opiate tolerance and synergistic agents when prescribing methadone View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mr Lee Martin Hughes, also known as Martin Lee Hughes · 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
Lee Martin Hughes was found deceased in his cell at HMP Wandsworth on 25 December 2021 while remanded in custody. The medical cause of death was methadone and benzodiazepine intoxication, and the jury concluded that drug-related misadventure was contributed to by neglect. Concerns included the assessment and prescribing of methadone, failure to respond appropriately to signs of sedation and impaired consciousness, and inadequate communication and escalation between healthcare disciplines.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to account for reduced opiate tolerance and synergistic agents when prescribing methadone
Wider context from the report “4. That practitioners when prescribing consider whether time spent in custody prior to remand may have reduced an individual's tolerance to opiates , especially when methadone is to be prescribed with a synergistic agent such as a benzodiazepine .
” Source location Mr Lee Martin Hughes, also known as Martin Lee Hughes · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the national service specification using learning from the case to strengthen prescribing and supply of sedating medicines.
Verbatim wording from the response “I am pleased to see from your Report that processes and procedures have been changed within HMP Wandsworth to address learning identified in this case and meet expectations in terms of prescribing and supplying sedating medicines safely.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and disseminate the withdrawal-treatment policy, including sedation safeguards, tolerance assessment, urine screening and clinical review requirements.
Verbatim wording from the response “2. The policy for the pharmacological treatment of drugs and alcohol withdrawal within the early days in custody has been reviewed, substantially revised and disseminated by the medicines management committee, with input from specialist substance misuse practitioners. It is a requirement that all prescribers of acute withdrawal medications at HMP Wandsworth have completed the RCGP drugs and alcohol management certificates to at least the part one level. This is the most recognised specialist substance misuse qualification in the UK. In addition, it should be noted that since Mr Hughes’ passing, HMP Wandsworth has employed a very experienced full time substance misuse practitioner, who oversees all of the five day review. This is the critical juncture to adjust the dosage and combination of sedating medications safely and consistently.” Source location Response from Oxleas NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss the case in a prescriber reflective-practice forum, focusing on individual history, clinical signs, investigations and cautious methadone dosing.
Verbatim wording from the response “3. This case has provoked a great deal of reflection on the balance of risks and benefits of methadone, especially in the first days of drug accumulation, and when prescribed alongside benzodiazepines or other sedatives. The findings and recommendations of Mr Hughes’ inquest have been shared with all prescribers. His case has already been discussed within a reflective practice forum for prescribers, focussing on the judicious interpretation of the individual patient’s history, clinical signs and investigations (such as urine drug screens), to prioritise safety with a ‘start low and go slow’ approach, even when this is unpopular with the patient.” Source location Response from Oxleas NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National guidance already addresses reduced opioid tolerance and reducing or withholding methadone when sedation is present.
Verbatim wording from the response “4. That practitioners, when prescribing consider whether time spent in custody before remand, may have reduced an individual’s tolerance to opiates; this is especially when methadone is to be prescribed with a synergistic agent such as benzodiazepines.” Source location Response from NHS England
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28 Feb 2024 Chloe Anne Tapp · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to establish medication doses and apply appropriate conversion factors View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
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Chloe Anne Tapp · 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
Chloe Anne Tapp, a 20-year-old with epilepsy and other medical conditions, suffered seizures and respiratory and cardiac arrest on 7 October 2021 and died in hospital on 8 October 2021. The principal concerns included delays transferring her to adult neurology, a telephone consultation despite her being non-verbal, an incorrect and inadequately documented medication tapering regime, and unanswered attempts to obtain clarification. Broader concerns were raised about staffing shortages, unsafe backlogs and difficulties responding to patients and carers within the neurology department.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to establish medication doses and apply appropriate conversion factors
Wider context from the report “An overworked consultant under considerable pressure, did not have time before or during the consultation to establish the dose that Chloe was taking and/or apply the appropriate conversion factor , for medications that can interact negatively at higher doses .
” Source location Chloe Anne Tapp · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.
Verbatim wording from the response “Having considered your Report and the concerns raised, a GIRFT visit to Mid and South Essex NHS Foundation Trust has been arranged to review the specific situation within their Neurology department.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The consultant had time to establish Chloe’s dose because it was documented and clinic capacity was available before the appointment.
Verbatim wording from the response “Chloe’s then current dose was readily available to the Consultant prior to her appointment, it was listed on the second page of the GP letter 10 August 2021. We have reviewed the clinic that took place on 3 September 2021 and can confirm that prior to Chloe’s appointment there was one unfilled clinical slot. This is a slot we plan to keep free for urgent/ unexpected cases; and there was one further patient who did not attend. We therefore consider the consultant had time to establish Chloe’s current dose prior to the consultation.” Source location Response from Mid and South Essex NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consultants already had 24/7 pharmacy support and online resources for dosage-conversion queries, although the available support was not accessed.
Verbatim wording from the response “Our consultants are also supported by the pharmacy team who are available 24/7 to assist with dosage conversion queries and ad hoc queries. They also have access to online support and resources. Unfortunately, the consultant did not access this support.” Source location Response from Mid and South Essex NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Many concerns about Chloe’s care fall within the NHS Foundation Trust’s remit rather than NHS England’s national programme or policy remit.
Verbatim wording from the response “In your Report you raise concerns over pressures being placed on neurology departments and that there was a recognised shortage of neurologists amid an increase in demand. This response focuses on the concerns raised relevant to NHS England national programme or policy. Many of your concerns around the quality of care delivered to Chloe sit within the remit of Mid and South Essex NHS Foundation Trust, and I note that you have also addressed your Report to them.” Source location Response from NHS England
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14 Feb 2024 Teresa Ann Bennett · Prevention of Future Deaths report North West Wales
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Concerns raised 1
Failure to conduct regular medication reviews when prescribing medicines that can depress the central nervous system View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Teresa Ann Bennett · 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
Teresa Ann Bennett, who had significant comorbidities and was taking multiple medications including Fentanyl, was found deceased at home on 1 December 2021. The inquest recorded multi-organ failure due to fatty liver and combined drug toxicity, with toxicological analysis identifying Fentanyl in the toxic and fatal range. Concerns included missed regular medication reviews, the absence of a standardised review process, and the risk of inadvertent overdose when medicines that depress the central nervous system are prescribed without regular reviews or specific advice.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to conduct regular medication reviews when prescribing medicines that can depress the central nervous system
Wider context from the report “(3) The risk of inadvertent overdose in individuals like Ms Bennett, where medication that can cause e.g drowsiness and fatigue, is prescribed alongside strong opiates and other drugs that have the ability to depress the central nervous system when such medicines are prescribed without regular reviews nor specific advice in respect of the associated risks issued to patients e.g in Ms Bennett’s case, she was instructed to simply “remove old patch and apply new patch every 72 hours”
” Source location Teresa Ann Bennett · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Risk-stratify patients lacking recent medication reviews to prioritise review according to medication-related risk.
Verbatim wording from the response “We have commenced benchmarking work on 21 February 2024 for all Health Board managed practices to identify all patients on regular repeat medication who have not got a medication review documented in the notes in the last 12-15 months. This work will be completed by 31 May 2024. These patients will then be risk stratified for medication review. This will occur parallel to implementing new procedures as outlined below.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a Health Board policy defining medication-review standards and risk-priority levels for managed practices.
Verbatim wording from the response “A pan Health Board policy is now being developed to outline the standards for medication review within our managed practices. This will be completed by 30 June 2024.” Source location Response from Betsi Cadwaladr University Health Board
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Concerns raised 1
Failure by ambulance crews to consider possible medication toxicity View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS Surrey and Sussex Integrated Care Board
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Susan Mary 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
Susan Mary Young died at home on 20 December 2022 after accidentally taking too many prescribed co-codamol tablets over a short period, causing fatal toxicity. The report identified that ambulance staff did not consider possible co-codamol toxicity because they did not have access to her GP records, and stated that earlier recognition and administration of Naloxone could have provided a good chance of survival.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure by ambulance crews to consider possible medication toxicity
Wider context from the report “The possible toxicity from the Co-codamol tablets was not a considered by the ambulance crew who attended to Mrs Young following a 999 call. The Ambulance Service was not aware that Mrs Young had recently been prescribed Co-Codamol as the Ambulance service does not currently have access to GP records.
There was a short period of time in which the Naloxone antidote could have been given and evidence was heard from the expert at the Inquest that if the toxicity had been recognised earlier and Naloxone administered there was a good chance that Mrs Young would have survived. As the Ambulance Service did not have the GP records readily available to them this meant that there was a missed opportunity to treat Mrs Young appropriately.
” Source location Susan Mary Young · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Intervention is limited to patient-safety issues arising from concerns about the GP practice, not ambulance-service matters.
Verbatim wording from the response “We have investigated the concerns raised by HM Coroner with the GP practice concerned (the Practice). As we are commissioners of primary care in Sussex, we can only intervene in this case in respect of issues that affect patient safety as a consequence of concerns about the GP practice.” Source location Response from NHS Sussex
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11 Sep 2023 Amanda Jane Kramer · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to review Zopiclone use despite high-risk medication-taking behaviour View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care North East London NHS Foundation Trust Practice
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 12
North East London NHS Foundation Trust
Review Zopiclone prescriptions within two weeks, identify existing patients for review, provide senior clinical oversight, and audit compliance six-monthly.
View source
North East London NHS Foundation Trust
Train staff in the safe prescribing and management of Z-drugs and benzodiazepines through repeat sessions.
View source
North East London NHS Foundation Trust
Coordinate primary and secondary care medication monitoring through an established integrated-care-system workstream and improve information sharing.
View source
North East London NHS Foundation Trust
Improve team handovers by documenting patient information, care plans and professional responsibilities, including primary-care prescribing arrangements, and audit effectiveness.
View source
North East London NHS Foundation Trust
Increase Crisis and Home Treatment team staffing through additional pharmacist posts.
View source
North East London NHS Foundation Trust
Use additional pharmacy capacity to improve discharge medication reconciliation, monitor and reconcile Zopiclone prescriptions, and provide medication education during transfers.
View source
Practice
Audit patients prescribed Zopiclone or Zolpidem to identify those requiring medication review.
View source
Practice
Review identified patients’ Zopiclone or Zolpidem medication and develop reduction, cessation or safer-alternative plans.
View source
Practice
Code completed medication plans in EMIS so healthcare professionals and administrators can follow them.
View source
Practice
Conduct medication reviews every four weeks where possible, focusing on reduction according to withdrawal symptoms, risk and support.
View source
Practice
Review Zopiclone and Zolpidem prescriptions as acute rather than repeat prescriptions and limit quantities to a maximum two-week supply.
View source
Practice
Apply the acute-prescription policy to new Zopiclone and Zolpidem requests.
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AI-generated summary
Amanda Jane Kramer · 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
Amanda Jane Kramer, aged 56, was found unresponsive at home on 31 December 2022 and died from an overdose of prescribed zopiclone. The report raised concerns that zopiclone had been prescribed for approximately 18 years without clear evidence that its ongoing need, associated risks, or adherence to dosage instructions had been reviewed, including after previous deliberate overdoses of prescribed medication.
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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 Zopiclone use despite high-risk medication-taking behaviour
Wider context from the report “1. Zopiclone is a drug licenced for the treatment of short-term insomnia. The risks associated with the drug are first, that it is a central nervous system depressant and second, that patients prescribed the drug can form a dependency upon it.
2. Mrs Kramer was prescribed Zopiclone for 18 years.
3. Despite the deceased being under the care of both a GP and a secondary mental health trust prior to her death. No clear evidence emerged in this inquest that anyone had reviewed Mrs Kramer's use of this drug even when Mrs Kramer had demonstrated a pattern of high-risk behaviour by deliberately overdosing on prescribed medication.
” Source location Amanda Jane Kramer · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Zopiclone prescriptions within two weeks, identify existing patients for review, provide senior clinical oversight, and audit compliance six-monthly.
Verbatim wording from the response “1. Patients who are initiated on Zopiclone now have a medical review of this medication within at least 2 weeks of the initial prescription date recorded in their care plan, whilst existing patients are being identified and reviewed. Senior clinical oversight has also been put in place to support this review for all patients prescribed this medication. The Trust has also put in place a 6 monthly audit process of this to help support this improvement in practice. The last of these audits was undertaken in October 2023, identifying one patient where a review was required, but that all other reviews had taken place. In circumstances where prescriptions remain in place for longer periods of time, the risks and rationale for this are discussed with patients and medical and care co-ordinator staff are keeping this under careful review.” Source location Response from North East London Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train staff in the safe prescribing and management of Z-drugs and benzodiazepines through repeat sessions.
Verbatim wording from the response “In support of this work, staff have received training on the safe prescribing and management of Z-drugs and Benzodiazepines and this is being arranged on a repeat basis, with the next session taking place on 29 November 2023.” Source location Response from North East London Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Coordinate primary and secondary care medication monitoring through an established integrated-care-system workstream and improve information sharing.
Verbatim wording from the response “2. A workstream has been established across the primary and secondary care partners in the North East London Integrated Care System. This is overseeing improvements to the co-ordination of medication monitoring for patients receiving Benzodiazepines and Z-Drugs, including significant work on the co-ordination of information between primary and secondary care to ensure that accurate information is in place to enable the effective review and monitoring of patients who have been prescribed such medication.” Source location Response from North East London Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve team handovers by documenting patient information, care plans and professional responsibilities, including primary-care prescribing arrangements, and audit effectiveness.
Verbatim wording from the response “3. The Trust has also worked with staff to ensure that there is effective handover of information between teams so that responsibilities are clear. In particular, there has been a focus on ensuring comprehensive documentation of patient information at the point of handover from one team to another. The effectiveness of this is being audited, and in the most recent audit undertaken (a random sample of 20 patients), all records were clear and reflected a comprehensive handover of the care plan and responsibilities for different professionals involved. This includes situations in which prescribing is taking place within primary care.” Source location Response from North East London Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase Crisis and Home Treatment team staffing through additional pharmacist posts.
Verbatim wording from the response “4. Staffing in Crisis and Home Treatment teams has been increased, with the addition of extra pharmacist posts. This will enable improved medicine reconciliation at the point of discharge from hospital, and ensure that prescriptions for Zopiclone amongst other medication are effectively monitored and reconciled throughout the patient’s journey. This increased capacity will also give more pharmacy support to work with individual patients at this point of transfer and transition, including work on medication education for both patients and prescribers that will help to address risks associated with these medications.” Source location Response from North East London Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use additional pharmacy capacity to improve discharge medication reconciliation, monitor and reconcile Zopiclone prescriptions, and provide medication education during transfers.
Verbatim wording from the response “4. Staffing in Crisis and Home Treatment teams has been increased, with the addition of extra pharmacist posts. This will enable improved medicine reconciliation at the point of discharge from hospital, and ensure that prescriptions for Zopiclone amongst other medication are effectively monitored and reconciled throughout the patient’s journey. This increased capacity will also give more pharmacy support to work with individual patients at this point of transfer and transition, including work on medication education for both patients and prescribers that will help to address risks associated with these medications.” Source location Response from North East London Foundation Trust
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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 Audit patients prescribed Zopiclone or Zolpidem to identify those requiring medication review.
Verbatim wording from the response “1. All patients being prescribed with Zopiclone or Zolpidem have been identified via an audit, enclosed with this response as Exhibit 1; the Practice is in the process of reviewing their medication – the progress of this can be demonstrated in the re-audit, undertaken in October 2023 (Exhibit 2). The goal is for each patient to have a plan in place to reduce and eventually stop the medication or change it to a safer alternative. Notification letters of these actions and patient leaflets will be sent to all patients on Zopiclone and Zolpidem. The completed plans have been coded onto the patients’ notes on the EMIS computer system for both healthcare professionals and administrators to be aware of the care plan and not deviate from it.” Source location Response from Wood Street Health Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review identified patients’ Zopiclone or Zolpidem medication and develop reduction, cessation or safer-alternative plans.
Verbatim wording from the response “1. All patients being prescribed with Zopiclone or Zolpidem have been identified via an audit, enclosed with this response as Exhibit 1; the Practice is in the process of reviewing their medication – the progress of this can be demonstrated in the re-audit, undertaken in October 2023 (Exhibit 2). The goal is for each patient to have a plan in place to reduce and eventually stop the medication or change it to a safer alternative. Notification letters of these actions and patient leaflets will be sent to all patients on Zopiclone and Zolpidem. The completed plans have been coded onto the patients’ notes on the EMIS computer system for both healthcare professionals and administrators to be aware of the care plan and not deviate from it.” Source location Response from Wood Street Health Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Code completed medication plans in EMIS so healthcare professionals and administrators can follow them.
Verbatim wording from the response “1. All patients being prescribed with Zopiclone or Zolpidem have been identified via an audit, enclosed with this response as Exhibit 1; the Practice is in the process of reviewing their medication – the progress of this can be demonstrated in the re-audit, undertaken in October 2023 (Exhibit 2). The goal is for each patient to have a plan in place to reduce and eventually stop the medication or change it to a safer alternative. Notification letters of these actions and patient leaflets will be sent to all patients on Zopiclone and Zolpidem. The completed plans have been coded onto the patients’ notes on the EMIS computer system for both healthcare professionals and administrators to be aware of the care plan and not deviate from it.” Source location Response from Wood Street Health Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct medication reviews every four weeks where possible, focusing on reduction according to withdrawal symptoms, risk and support.
Verbatim wording from the response “2. Where possible, all patients on Zopiclone or Zolpidem will have a medication review every 4 weeks; such review will focus on reducing the regimen of their medication, depending on withdrawal symptoms, level of risk and support structure.” Source location Response from Wood Street Health Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Zopiclone and Zolpidem prescriptions as acute rather than repeat prescriptions and limit quantities to a maximum two-week supply.
Verbatim wording from the response “3. All prescriptions of Zopiclone and Zolpidem have been reviewed to ensure they are acute, rather than repeat prescriptions; this will be a policy for new requests as well. This will also provide opportunities for more frequent reviews and discussion on how the withdrawal plan is being achieved with the patient. All quantities on prescription are reduced to a maximum 2-week supply.” Source location Response from Wood Street Health Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Apply the acute-prescription policy to new Zopiclone and Zolpidem requests.
Verbatim wording from the response “3. All prescriptions of Zopiclone and Zolpidem have been reviewed to ensure they are acute, rather than repeat prescriptions; this will be a policy for new requests as well. This will also provide opportunities for more frequent reviews and discussion on how the withdrawal plan is being achieved with the patient. All quantities on prescription are reduced to a maximum 2-week supply.” Source location Response from Wood Street Health Centre
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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 Prescribing and medication review decisions rest with the GP or responsible clinician, who must determine treatment with the patient.
Verbatim wording from the response “As I am sure you will be aware, GPs and other prescribers are ultimately responsible for their own prescribing decisions. The decision to prescribe a particular product is a clinical one and should be based on the patient’s medical needs. The process of reviewing medication is one in which the GP or responsible clinician work together” Source location Response from Department of Health and Social Care
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6 Jul 2023 Robert Newton Stevenson · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 2
Failure to reference the potential rare side effect when prescribing Ciprofloxacin and Quinolone antibiotics View source Lack of prescribing doctors’ awareness of the potential rare side effect View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Robert Newton Stevenson · 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
Robert Newton Stevenson, a 63-year-old retired consultant cardiologist and general physician, left home on 30 May 2022 and was later found hanging; resuscitation attempts were unsuccessful. The report raised concern about a possible rare link between ciprofloxacin and suicidal behaviour, including whether prescribing doctors were sufficiently aware of and communicating this potential side effect.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to reference the potential rare side effect when prescribing Ciprofloxacin and Quinolone antibiotics
Wider context from the report “During the inquest I was referred by Mr Stevenson’s treating urologist to published literature relating to Ciprofloxacin and Quinolone antibiotics and a potential rare link to suicide behaviour in patients, although I found on the balance of probabilities that it remained unclear that he was suffering from this side effect, it remained possible for this to be the case.
• I heard evidence to suggest that the prescribing doctor did not reference this side effect at the time of issuing the prescription to Mr Stevenson , since it was not in accord with current advice.
• I also heard evidence to suggest that prescribing doctors may not be fully aware of this rare side effect, and that patient’s suffering from depression may be more vulnerable to it.
• I am therefore concerned that this potential risk has not been given sufficient emphasis and I would ask you to consider the appropriateness of reviewing the current guidelines as to the dispensation of the drug to patients by clinicians and increasing the awareness of the side effect in order to monitor and mitigate the risks.
” Source location Robert Newton Stevenson · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of prescribing doctors’ awareness of the potential rare side effect
Wider context from the report “During the inquest I was referred by Mr Stevenson’s treating urologist to published literature relating to Ciprofloxacin and Quinolone antibiotics and a potential rare link to suicide behaviour in patients, although I found on the balance of probabilities that it remained unclear that he was suffering from this side effect, it remained possible for this to be the case.
• I heard evidence to suggest that the prescribing doctor did not reference this side effect at the time of issuing the prescription to Mr Stevenson, since it was not in accord with current advice.
• I also heard evidence to suggest that prescribing doctors may not be fully aware of this rare side effect , and that patient’s suffering from depression may be more vulnerable to it.
• I am therefore concerned that this potential risk has not been given sufficient emphasis and I would ask you to consider the appropriateness of reviewing the current guidelines as to the dispensation of the drug to patients by clinicians and increasing the awareness of the side effect in order to monitor and mitigate the risks.
” Source location Robert Newton Stevenson · Prevention of Future Deaths report
Open source report
22 Feb 2023 Jacqueline Sharman CAMPBELL · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1
Failure to actively identify patients taking high-risk medication combinations and rationalize or reduce their medications View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Hilltops Medical Centre NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Hilltops Medical Centre
Audit high-dose opioid patients, arrange reviews, and consider dose reduction where appropriate.
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Hilltops Medical Centre
Identify and review patients prescribed opioids with gabapentinoids and benzodiazepines or Z-drugs.
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Hilltops Medical Centre
Maintain three-monthly medication reviews using recall systems, preferably face to face and with a named clinician.
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Hilltops Medical Centre
Use the Arden’s Opioid Initiation and Monitoring template during medication reviews.
View source
NHS England
Operate a national programme to reduce harm from high-dose opioids prescribed for non-cancer pain.
View source
NHS England
Support Integrated Care Systems to develop, implement, adapt and share effective improvements in chronic pain and opioid prescribing care.
View source
NHS England
Develop national resources supporting consistent repeat-prescribing processes and structured medication reviews for patients at risk from multiple medicines.
View source
NHS England
Publish a national framework to help systems improve personalised care for adults prescribed dependence- or withdrawal-associated medicines.
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AI-generated summary
Jacqueline Sharman CAMPBELL · 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
Jacqueline Sharman CAMPBELL was found collapsed at home after living with chronic back pain for more than 20 years and taking multiple prescribed medicines. The inquest concluded that she likely inadvertently overdosed on tramadol, which in combination with other medicines had a synergistic effect causing respiratory depression and death. The principal concern was the safety risk of polypharmacy involving gabapentinoids and opioids, particularly their cumulative and synergistic effects on the central nervous system.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to actively identify patients taking high-risk medication combinations and rationalize or reduce their medications
Wider context from the report “Her GP, ████████, gave clear and candid evidence. I accept the management of patients who describe intractable debilitating pain is challenging and difficult and that requests for other or increasing doses of medication can be difficult to resist. ████████ agreed that the prescribing of the various drugs identified had potential to be dangerous. He told me that after a certain point the benefits of increasing or adding doses or medications in terms of pain relief were minimal. This scenario seems to be an on individuals one for GP’s and patients alike.
████████ told me that subsequent to Ms Campbell’s death the practice had convened and discussed the circumstances and agreed on regular reviews for patients taking these sorts of medication. There were no plans identified to actively look for these patients and to work to rationalize and / or reduce their medications.
I am of the view that polypharmacy including gabapentinoids and opiates represents a severe safety risk in patients with a iatrogenic drug dependency. I consider that the risk in individuals like Ms Campbell of an inadvertent overdose of medications which have a cumulative and synergistic effect to depress the central nervous system can easily become extreme and lead to death. There have been a number of deaths in the Milton Keynes, Bedfordshire and Luton areas related to concomitant use of high dose and combination gabapentinoids and opioids.
” Source location Jacqueline Sharman CAMPBELL · Prevention of Future Deaths report
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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 Audit high-dose opioid patients, arrange reviews, and consider dose reduction where appropriate.
Verbatim wording from the response “2) In March 2022 we carried out an audit of patients on high dose opioids (> 120mg oral morphine equivalent) and arranged a review of these patients. We repeated this Audit in November- December 2022 and are currently in the process of redoing this audit and consideration given to dose reduction where appropriate.” Source location Response from Hilltop Surgery
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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 Identify and review patients prescribed opioids with gabapentinoids and benzodiazepines or Z-drugs.
Verbatim wording from the response “4) We have identified other patients on combination of Opiates+Gabapentinoids+Benzodiazepines/Z-drugs who have now been reviewed.” Source location Response from Hilltop Surgery
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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 Maintain three-monthly medication reviews using recall systems, preferably face to face and with a named clinician.
Verbatim wording from the response “5) We are ensuring that these patients are reviewed 3 monthly, with robust recall systems in place, preferably face to face and with named clinician to review and rationalise the medication.” Source location Response from Hilltop Surgery
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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 Use the Arden’s Opioid Initiation and Monitoring template during medication reviews.
Verbatim wording from the response “7) We have discussed and agreed that patients on a combination of Opiates+gabapentinoids+Benzodiazepines/Z drugs are reviewed 3 monthly and patients on high dose Opioids are reviewed 6 monthly. We agreed to use the Arden’s ‘Opioid Initiation and Monitoring’ template during the reviews to ensure all areas of review are covered.” Source location Response from Hilltop Surgery
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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 Operate a national programme to reduce harm from high-dose opioids prescribed for non-cancer pain.
Verbatim wording from the response “The NHS Medicines Safety Improvement Programme (which forms a key part of the NHS Patient Safety Strategy) has launched a focussed programme of work to improve the care of people with chronic pain and a reduction in the use of prescribed opioids by aiming to reduce harm from opioid medicines by reducing high dose prescribing” Source location Response from NHS England
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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 Support Integrated Care Systems to develop, implement, adapt and share effective improvements in chronic pain and opioid prescribing care.
Verbatim wording from the response “(>120mg oral Morphine equivalent), for non-cancer pain by 50%, by March 2024. The programme has been in place since January 2021. The national programme is supporting Integrated Care Systems to learn from, adapt and adopt effective practice using a whole-system improvement approach.” Source location Response from NHS England
Open published response
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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 Develop national resources supporting consistent repeat-prescribing processes and structured medication reviews for patients at risk from multiple medicines.
Verbatim wording from the response “The National overprescribing review report commissioned by DHSC in 2018 evaluated the extent, causes and consequences of overprescribing and made 20 recommendations to address it. NHS England aims to make long term sustainable reductions to overprescribing and is working on several outputs to help implement the review’s recommendations. Outputs include national resources to help practices improve the consistency of repeat prescribing processes, supported by appropriate training; and resources to enhance structured medication reviews for patients who may experience harm from taking multiple medicines.” Source location Response from NHS England
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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 Publish a national framework to help systems improve personalised care for adults prescribed dependence- or withdrawal-associated medicines.
Verbatim wording from the response “In March 2023, NHS England published ‘Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for ICBs and primary care’. The framework includes five actions, resources, and case studies to help systems develop plans that can support people who are taking medicines associated with dependence and withdrawal symptoms by:” Source location Response from NHS England
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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 ICBs are responsible for commissioning chronic pain and opioid-withdrawal support services for their geographically covered populations.
Verbatim wording from the response “Commissioning of services to support people with chronic pain (including services to support people to safely withdraw from opioid use) now lies with the ICBs. NHS England expects ICBs to commission appropriate services to meet the needs of the population that the ICB geographically covers.” Source location Response from NHS England
Open published response
7 Jul 2022 Seema Pravin HARIBHAI · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to recognise prescribed medicines as a possible cause of harm View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Seema Pravin HARIBHAI · 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
Seema Haribhai, who had increasingly disabling psoriatic arthritis, took herbal remedies prescribed by an Ayurvedic practitioner and developed liver failure, dying some weeks later. The investigation determined that she died as a consequence of the administration of Ayurvedic medicines intended to treat psoriatic arthritis. Concerns included the practitioner’s failure to recognise the possible harm from the medicines or advise their immediate cessation, the lack of regulation and evidence of quality control, and shortcomings in the GP’s assessment and response to her symptoms and abnormal blood test.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise prescribed medicines as a possible cause of harm
Wider context from the report “However, when she first discovered that her patient had developed a yellow discolouration, whilst she recognised that the liver was probably responsible, she did not recognise that the cause might be her own prescription . She did not advise the only course of action with the potential to save Seema Haribhai’s life: an immediate cessation of all the herbal remedies.
Even when she gave evidence in court, the Ayurvedic practitioner did not seem to canvass the possibility that the medicines she had prescribed could have caused harm. She had at one stage advised her patient to have a routine blood test, but she had not at any stage advised immediate attendance at a hospital emergency department.
” Source location Seema Pravin HARIBHAI · Prevention of Future Deaths report
Open source report
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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 Investigated how the incident occurred to inform members and help prevent recurrence.
Verbatim wording from the response “Ayurveda is not currently regulated in the UK, something the APA had campaigned for in the past. Consequently, the APA has no power to oversee, or control how individual’s practice other than through advice and guidance. However, as an association, the APA has taken this incident very seriously and has investigated as far as possible how this unfortunate event occurred in order to alert its members and prevent a reoccurrence.” Source location Response from Ayurvedic Professionals Association
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation AYUSH is identified as the authority able to assess whether the Ayurvedic herbs used could cause harm.
Verbatim wording from the response “Regarding whether the APA can identify if the Ayurvedic herbs used by the Dr. in this instance, who holds a Bachelor of Medicine and Surgery (BAMS) degree from India, had the potential to cause harm, AYUSH is likely to be the only authority able to answer this question and it may be helpful if the PFD could also be directed to AYUSH via the Indian High Commission. AYUSH can be contacted via its website at:
https://www.ayush.gov.in
https://main.ayush.gov.in
https://www.hcilondon.gov.in
If it will assist the Coroner, the APA will be happy to make this representation to AYUSH.” Source location Response from Ayurvedic Professionals Association
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providing individual advice on treatment protocols and identifying herbal harms through training are outside the association’s remit.
Verbatim wording from the response “As previously mentioned, the APA is a member’s association for pre-trained professionals who have undergone extensive training that includes them being able to identify situations where they (a BAMS Dr.) may need to advise on whether their patient needs more urgent medical attention, specifically a medical intervention. In the case of the BAMS Dr. involved in this incident, this training is set out in the curriculum set by the National Commission for Indian Systems of Medicine as she held a BAMS degree. Details of the training provided to BAMS doctors can be found at https://ncismindia.org, but it is not within the APA’s remit to provide individual advice on treatment protocols.” Source location Response from Ayurvedic Professionals Association
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.