Recurring concern

Insufficient assessment of patients’ current drug use before drug treatment

First to latest report 10 Jan 2014 — 1 Aug 2019

Reports that mention this concern
4
Times this concern has been raised
5
Stated actions linked to this concern
5

What this concern includes

Includes deficiencies in obtaining, documenting or clinically assessing a patient’s current drug use, frequency, drug content or dependence when that information is needed to make safe drug-treatment, prescribing, supervision or observation decisions.

What is not included
  • Excludes generic failures to undertake risk assessments where the patient’s drug use is not a material part of the concern.
  • Excludes unsafe prescribing concerns that do not involve inadequate assessment of current drug use, usage frequency, drug content or dependence.
  • Excludes hazards concerning the unknown composition of illicit or Internet-supplied drugs where the report does not identify a deficient clinical assessment before treatment.
  • Excludes failures limited to treatment monitoring or review after an adequate pre-treatment assessment.

Reports and published responses 4 reports

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

  1. Manchester South

    AI-generated summary

    Deborah Chapman · 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

    Deborah Chapman, who had COPD, chronic pain, and continued to misuse heroin and crack cocaine, was found unresponsive at home on 3 March 2019 and was pronounced dead at 7.06am. The post-mortem attributed her death to the combined toxic effects of heroin, oxycodone and pregabalin, together with COPD. Concerns included whether her ongoing illicit drug use and the risks of combining prescribed and illicit drugs had been adequately assessed and recorded when prescribing oxycodone and pregabalin.

    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 system for obtaining and recording illicit drug misuse information to support informed prescribing risk assessment and review

    Wider context from the report

    “5. Furthermore, the evidence did not reveal any system in place at the West Timperley Medical Centre to ensure that the information about illicit drug misuse is obtained and recorded from patients in order to ensure that an informed assessment of the risks of the concomitant use prescribed and illicit drugs could be made and reviewed. ”

    Source location

    Deborah Chapman · 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 enquire about patients’ current or continued illicit drug misuse

    Wider context from the report

    “2. The evidence I heard from the records held at the medical centre did not reveal the extent to which any enquiry was made of Ms Chapman as to her current misuse of illicit drugs either on the occasion of her re-joining the medical practice as a patient in July 2018 or at subsequent consultations. There were clear signs of a dependence on the prescribed opiate drugs and the medical records equally revealed long-term illicit opiate misuse. 3. The evidence I heard from the medical records held at the medical centre did not reveal, beyond the admitted dependence on the prescribed medication, what enquiry had been made from Ms Chapman in relation to her continued misuse of illicit drugs or her response to those enquiries. 4. In the absence of that information, it was not possible, from the medical records, to ascertain what level of risk the continued illicit misuse of opiates posed to Ms Chapman and therefore, whether, on an informed basis, pregabalin and oxycodone were appropriate prescriptions. ”

    Source location

    Deborah Chapman · 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

    Discuss illicit-drug-use recording requirements and clarify that stopped intravenous drug use does not establish cessation of all illicit drug use.

    Verbatim wording from the response

    “In the first instance, Mrs Chapman’s death was discussed in a Primary Care Team Meeting. In particular, the need to ensure we have an up to date record of all illicit drug use was emphasised and a reminder of the fact that a record of intravenous drug abuse having been stopped does not mean that all illicit drug use has been stopped.”

    Source location

    2019-0280-Response-from-West-Timperley-Medical-Centre-Redacted
    Page 1 · response
    Published 18 October 2019

    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

    Search the clinical system regularly for patients receiving regular opiate analgesia or Pregabalin who have a history of drug misuse.

    Verbatim wording from the response

    “We have put in place a regular search of our clinical system to identify patients that are taking regular opiate analgesia and who have a past history of drug misuse. A similar search has been undertaken for those patients taking regular Pregabalin. The searches have identified 16 patients taking regular opiate analgesia with a history of drug misuse and 7 patients taking Pregabalin with a history of past drug misuse. We are currently contacting those patients to ensure that we have an up to date record of their current illicit drug use.”

    Source location

    2019-0280-Response-from-West-Timperley-Medical-Centre-Redacted
    Page 1 · response
    Published 18 October 2019

    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

    Contact identified patients to update records of their current illicit drug use.

    Verbatim wording from the response

    “We have put in place a regular search of our clinical system to identify patients that are taking regular opiate analgesia and who have a past history of drug misuse. A similar search has been undertaken for those patients taking regular Pregabalin. The searches have identified 16 patients taking regular opiate analgesia with a history of drug misuse and 7 patients taking Pregabalin with a history of past drug misuse. We are currently contacting those patients to ensure that we have an up to date record of their current illicit drug use.”

    Source location

    2019-0280-Response-from-West-Timperley-Medical-Centre-Redacted
    Page 1 · response
    Published 18 October 2019

    Open published response

  2. South Yorkshire (Eastern)

    AI-generated summary

    Lyndsey Holt · 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

    Lyndsey Holt, who was 37 weeks pregnant, collapsed after a gastric ulcer perforated and caused catastrophic bleeding. She died the following morning after emergency surgery and resuscitation; concerns included the telephone prescribing of methadone without sufficient information, assessment, or early medical review, and the provision of a seven-day supply to a methadone-naïve patient.

    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 detail regarding drugs taken, usage frequency and dependence before methadone prescribing

    Wider context from the report

    “The circumstances in which the methadone was prescribed namely: (1) Doing so over the telephone with no face to face consultation. (2) Consequent lack of detail regarding: 2.1 the drugs being taken by Miss Holt 2.2 the frequency with which they were being taken 2.3 the degree if any, of her dependence 2.4 absence of assessment of any psychological issues (3) Providing a methadone naïve patient with a 7 day supply. (4) Lack of medical review during the initial phase. ”

    Source location

    Lyndsey Holt · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. County Durham and Darlington

    AI-generated summary

    David Peter Greenfield · 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

    David Peter Greenfield, aged 29, was admitted to hospital for alcohol detoxification and was found unresponsive in his bedroom less than 24 hours later. The report states that his death involved pre-existing heart disease, respiratory depression linked to obesity and the effects of drugs. Concerns included staff experience and understanding of risks associated with methadone and respiratory depression, and the absence of drug screening for patients admitted for alcohol detoxification, which impeded meaningful risk assessment.

    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

    Inability of prescribing doctors to undertake meaningful treatment and supervision risk assessments when patients' drugs are unknown

    Wider context from the report

    “2. Evidence was given if a patient enters The Priory with a view to a drug treatment issue then that patient would be screened for drugs. If a patient is admitted to The Priory for an alcohol detoxification programme then there is no screening for drugs. The deceased was known to take methadone. Other drugs were found at post mortem in his system and in combination with alcohol detoxification medication there is an increased risk of respiratory depression and in the absence of the prescribing doctor knowing with a degree of certainty (notwithstanding any statements made by a patient) as to what drugs are in a patients system then a full and proper risk assessment as to the nature of the treatment to be offered and the level of supervision and observations to be instituted (i.e. a meaningful risk assessment) cannot be undertaken and this lacuna in admission procedures could well lead to an increased risk of similar fatalities in the future. ”

    Source location

    David Peter Greenfield · 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

    Provide detoxification hospitals with urine drug-screening kits and instruct staff to test patients where illicit-drug use is indicated.

    Verbatim wording from the response

    “We are in agreement with you that we should routinely use urine drug screens across all of our detoxification services as part of the assessment process and where necessary on an on-going basis thereafter. Since the request we have reviewed this practice and learnt that a number of hospitals are routinely undertaking urine drug screens on those patients who are admitted for alcohol detoxification. Our intention is to ensure that our hospitals all have access to urine drug screening kits and that staff are aware that a test should be undertaken if there is any indication that the patient may be at risk of using illicit drugs prior to or at the point of admission. Our intention is to ensure that these kits are readily available at relevant hospital sites by the end of February 2014.”

    Source location

    2014-0518-Response-by-Priory-Group
    Page 2 · response
    Published 27 November 2014

    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

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