Recurring concern

Unsafe prescribing for patients consuming excessive alcohol

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First reported 10 Jan 2014•Latest report 9 Aug 2022

Definition

What this concern includes

Includes failures in prescribing arrangements specifically addressing patients who consume alcohol excessively, including identifying and communicating alcohol use to prescribers, assessing interaction and overdose risks, setting appropriate dosage or duration, providing relevant advice and arranging follow-up review.

Not included

  • Excludes general unsafe prescribing where excessive alcohol use is not a material part of the asserted concern.
  • Excludes generic medication communication, documentation or policy deficiencies unless they directly impair prescribing for a patient consuming excessive alcohol.
  • Excludes alcohol-use treatment, withdrawal management and intoxication response where medication prescribing risk is not the shared unsafe condition.
  • Excludes medication administration, dispensing or supply failures after a safe alcohol-sensitive prescribing decision has been made.
Reports
4

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2014–2022

First to latest report issue date

Stated actions
8

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS Greater Manchester Integrated Care Board2
Browning Street Surgery1
General Medical Council1
Greater Manchester Health and Social Care Partnership1
Recipient name withheld1
Swanage Medical Practice1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Dorset

    AI-generated summary

    Mathew Christopher Moore · 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

    Mathew Christopher Moore died on 7 August 2021 in Bournemouth, Dorset, having attached a rope as a ligature. The report records concerns about the combined use of prescribed medication and excess alcohol, including potentially unsafe prescribing, a lack of documented communication of concerns to Mr Moore, and the need for clearer policies, dosage review, follow-up, and information-sharing within the surgery.

    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 policy for patients prescribed medication while consuming alcohol to excess

    Wider context from the report

    “2. I have concerns with regard to the following: i. There could be the death of a person in the future due to combined use of ████████ and excess alcohol and I request that consideration is given to creating a policy at the surgery to cover patients who are prescribed ████████, at the same time as consuming alcohol to excess. ii. I would request consideration is given as to the advice to be given in the circumstances where a patient is not being seen face to face, but via another healthcare worker. iii. Further, consideration should be given to the amount and dosage that should be prescribed in these circumstances and whether there should be a documented process to highlight any concerns about the use of ████████ being brought to the patient’s attention as soon as possible. iv. I would request consideration is given that within the policy there is provision for a follow up face to face meeting to review the medication. v. I would request consideration is given to the policy being available to all healthcare staff in the surgery. ”

    Source location

    Mathew Christopher Moore · Prevention of Future Deaths report
    Page 1 · concerns

    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

    Create an electronic-record alert for drugs in the specified prescribing group, warning prescribers about dosage and alcohol-related risks.

    Verbatim wording from the response

    “In response to Mr Nicholls concerns and suggestions of the 9th August, I can also confirm that we have now created a protocol alert that triggers on the patient electronic record when any drugs in the ████████ prescribing group are issued. This alert warns the prescriber to consider the amount and dosage being prescribed, and highlights the risk of the use of the drug combined with excess alcohol use. The alert also asks them to consider arranging a face to face medication review with the patient. This alert is available to all staff at the Practice who issue medications in the ████████ prescribing group.”

    Source location

    Response from Swanage Medical Practice
    Page 1 · response
    Published 30 September 2022

    Open published response
  2. Manchester South

    AI-generated summary

    Elaine Michelle Inns · 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

    Elaine Michelle Inns was found dead at her home on 18 January 2021. The inquest heard that she continued to be prescribed powerful painkillers despite significant alcohol use and use of liquid morphine without clearly following dosage instructions; the medical cause of death involved the combined toxic effects of ethanol and prescribed medicines.

    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 account for significant alcohol use when prescribing powerful painkillers

    Wider context from the report

    “The inquest heard that Elaine Inns continued to be prescribed a combination of medication including a number of powerful painkillers although it was well understood that she was also using alcohol in significant quantities whilst taking her prescribed medication. The evidence before the court also indicated that she would use the prescribed liquid morphine without clearly following the recommended dosage instructions. She continued to be prescribed it. ”

    Source location

    Elaine Michelle Inns · Prevention of Future Deaths report
    Page 1 · concerns

    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 up-to-date opiate prescribing guidance across Stockport practices.

    Verbatim wording from the response

    “Having reviewed this overall investigation and the circumstances which led to the issue of your Regulation 28 report, I reach the conclusion that the key issue is the prescribing of opiates and I am satisfied that appropriate steps have been taken to ensure the safe prescribing of opiate medication at the individual practice and across the wider Stockport GP community. I will ensure that the most up to date opiate prescribing guidance is shared across our practices and work with colleagues across our system to ensure adherence to best practice guidance.”

    Source location

    2021-0285-Response-from-Stockport-CCG_Published.pdf
    Page 4 · response
    Published 2 September 2021

    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

    Work with system colleagues to ensure adherence to best-practice opiate prescribing guidance.

    Verbatim wording from the response

    “Having reviewed this overall investigation and the circumstances which led to the issue of your Regulation 28 report, I reach the conclusion that the key issue is the prescribing of opiates and I am satisfied that appropriate steps have been taken to ensure the safe prescribing of opiate medication at the individual practice and across the wider Stockport GP community. I will ensure that the most up to date opiate prescribing guidance is shared across our practices and work with colleagues across our system to ensure adherence to best practice guidance.”

    Source location

    2021-0285-Response-from-Stockport-CCG_Published.pdf
    Page 4 · response
    Published 2 September 2021

    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

    Existing prescribing safeguards are considered sufficient to ensure safe opiate prescribing across the individual practice and wider Stockport GP community.

    Verbatim wording from the response

    “Having reviewed this overall investigation and the circumstances which led to the issue of your Regulation 28 report, I reach the conclusion that the key issue is the prescribing of opiates and I am satisfied that appropriate steps have been taken to ensure the safe prescribing of opiate medication at the individual practice and across the wider Stockport GP community. I will ensure that the most up to date opiate prescribing guidance is shared across our practices and work with colleagues across our system to ensure adherence to best practice guidance.”

    Source location

    2021-0285-Response-from-Stockport-CCG_Published.pdf
    Page 4 · response
    Published 2 September 2021

    Open published response
  3. Manchester South

    AI-generated summary

    Wendy Margaret Wilkes · 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

    Wendy Margaret Wilkes was found at her home on 6 August 2019, with toxicology showing a fatal level of ethanol and concomitant use of gabapentin, zopiclone, diazepam and amitriptyline. Concerns were raised about the absence of a clear system for alert notes and follow-up reviews, and about whether prescribers were aware of her high alcohol use and assessed the risks of mixing alcohol with her medication.

    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 ensure prescribers are aware of high alcohol use

    Wider context from the report

    “The inquest heard that the GP practice did not appear to have a system to ensure that prescribers were aware that her alcohol use was high and to assess the risk of mixing alcohol with the prescribed medication. ”

    Source location

    Wendy Margaret Wilkes · 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 assess the risk of mixing alcohol with prescribed medication

    Wider context from the report

    “The inquest heard that the GP practice did not appear to have a system to ensure that prescribers were aware that her alcohol use was high and to assess the risk of mixing alcohol with the prescribed medication. ”

    Source location

    Wendy Margaret Wilkes · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Flag patients at risk from neuropathic medication and alcohol dependence, conduct medication reviews, and contact them about medication and alcohol consumption.

    Verbatim wording from the response

    “Alert Note/Review System effective from 25 February 2020 The practice has identified relevant existing patients by running reports for patients coded on the practice’s clinical system as using neuropathic medication, cross referenced with patients coded with alcohol dependency who have had an intentional or accidental overdose. A “flag” is now placed on these patients’ medical records and a medication review is undertaken. The patients are then contacted to discuss their medication and their alcohol consumption.”

    Source location

    2020-0095-Response-from-Tameside-Glossop_Redacted
    Page 2 · response
    Published 18 May 2020

    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 non-clinical staff to share intentional or accidental overdose information with practice GPs.

    Verbatim wording from the response

    “To further support this process, non-clinical staff have been trained to ensure that information related to intentional or accidental overdoses are shared with the General Practitioners in the practice; so the process described above can be followed.”

    Source location

    2020-0095-Response-from-Tameside-Glossop_Redacted
    Page 2 · response
    Published 18 May 2020

    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

    Develop and distribute guidance to practices on identifying and managing patients prescribed neuropathic drugs or opioids who may be alcohol-dependent.

    Verbatim wording from the response

    “Tameside and Glossop Clinical Commissioning Group (CCG) actions ████████, Director of Commissioning, is accountable to ensure that in line with the Coroner’s request, the following actions will be undertaken:”

    Source location

    2020-0095-Response-from-Tameside-Glossop_Redacted
    Page 2 · response
    Published 18 May 2020

    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

    Issue an alert to all GP practices about alert notes, follow-up reviews and considering systems to identify high alcohol use during prescribing.

    Verbatim wording from the response

    “3. An alert will be issued to all GP practices to ensure that they have clear systems of alert notes/follow up review appointments for individuals with extensive prescribed medications. The alert also requests GP practices consider how their systems can alert prescribers to patients with high alcohol usage when prescribing medications to ensure effective risk assessments can be carried out.”

    Source location

    2020-0095-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership
    Page 2 · response
    Published 18 May 2020

    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 named Clinical Commissioning Group is responsible for addressing the concerns raised about GP practice alert systems and prescribing risk assessment.

    Verbatim wording from the response

    “I have noted that your Regulation 28 letter has also been sent to the Clinical Commissioning Group concerned and I will leave it to the named respondent to address the concerns which you have addressed. My letter therefore addresses the issues that fall within the remit of GMHSCP.”

    Source location

    2020-0095-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership
    Page 2 · response
    Published 18 May 2020

    Open published response
  4. Staffordshire South

    AI-generated summary

    Pauline Meredith · 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

    Pauline Meredith, aged 42, was found dead in her flat on 30 August 2013. Her death was attributed to mixed drug toxicity, including a fatal level of morphine, excessive levels of tramadol and propranolol, and alcohol. Concerns included the amount and review of prescribed medication, the addition of morphine alongside existing medication and alcohol dependence, the response to family concerns, the absence of team meetings, and delays in involving community mental health services.

    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 safely assess morphine prescribing alongside high-dose painkillers and alcohol dependence

    Wider context from the report

    “(2) The more recent addition of morphine to the prescription for a patient already on a high dose of pain killers and with alcohol dependence ”

    Source location

    Pauline Meredith · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Consider and initiate independent medication reviews by asking an uninvolved doctor to review complex patients’ medication when appropriate.

    Verbatim wording from the response

    “3) Miss Meredith had seen 3 other doctors and the nurse practitioner in previous 8 months before her death. Having reflected on this case, I recognise that it can often be useful to have another clinician with a fresh pair of eyes looking at patients with chronic problems. The practice will consider whether there are circumstances where the medication reviews are best carried out by another doctor who is not so involved with the case. This would be actioned by the regular doctor asking for a medication review by a colleague who was not involved in management of the case. This is to be initiated from now.”

    Source location

    2014-0011-Response-by-Browning-Street-Surgery
    Page 9 · response
    Published 10 January 2014

    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

    Morphine was considered appropriate because pain was significant, alternatives had failed, alcohol intake had reduced, and prescribing was regularly reviewed.

    Verbatim wording from the response

    “In response to her request for additional analgesia in February 2013, options were limited. For pain relief, she was already taking tramadol 50mg 2 tablets four times daily (maximum dose) plus paracetamol 500mg 2 tablets four times daily (maximum dose) and diclofenac 50mg three times daily (maximal usual dose). I was reluctant to prescribe co-codamol or codeine or dihydrocodeine. These had previously been prescribed with little effect on her pain. She was already on a strong anti-inflammatory painkiller (diclofenac) and so there was little value in changing to an alternative anti-inflammatory. As Miss Meredith’s pain appeared significant, I decided to prescribe MST (slow release morphine sulphate tablets) 1 tablet twice daily at the lowest dose possible, 10mg. The treatment plan initially was to prescribe this for one week and then review whilst she regained control of her pain.”

    Source location

    2014-0011-Response-by-Browning-Street-Surgery
    Page 3 · response
    Published 10 January 2014

    Open published response
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Data last updated 7 September 2026