Recurring concern

Inadequate safeguards against misuse of medicines with abuse potential

Get email alerts

Request correction

First reported 8 May 2018•Latest report 4 Dec 2025

Definition

What this concern includes

Includes prescribing, repeat-prescribing, replacement-prescription, monitoring, review or escalation controls specifically intended to identify and manage misuse or abuse risks for medicines with abuse potential, including where a patient's substance-use history is relevant.

Not included

Excludes ordinary prescribing errors, dose or formulation mistakes and drug interactions where misuse or abuse risk is not the identified unsafe condition.
Excludes excessive medication quantities unless the report specifically links them to controlling misuse or abuse risk rather than quantity governance alone.
Excludes physical medication-security failures involving storage or unauthorised access where prescribing or clinical misuse-risk controls are not deficient.
Excludes generic incident investigation, documentation or governance failures unless they directly concern management of misuse or abuse risk for a medicine.

Reports: 14
Individual concerns: 17
Date range: 2018–2025
Stated actions: 44

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

NHS Greater Manchester Integrated Care Board2

Addison House Surgery1

Alvaston Medical Centre1

Brinnington Surgery1

Department of Health and Social Care1

Gloucestershire Hospitals NHS Foundation Trust1

Limehouse Practice1

NHS Brighton and Hove Clinical Commissioning Group1

NHS South Yorkshire Integrated Care Board1

NHS Surrey and Sussex Integrated Care Board1

North Laine Medical Centre1

Petroc Group Practice1

Royal College of General Practitioners1

The Village Medical Centre1

Tredegar 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.

18 Nov2019
Manchester North
Concerns raised1
1. Failure to extend detoxification follow-up beyond the medication course to explore continued substance use
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Alex Grady · 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

Alex Grady was found deceased in his bed on 26 February 2019 and died from combined toxicity involving prescribed and non-prescribed medication and illicit drugs. Concerns included the adequacy of support and follow-up when alcohol detoxification is managed solely by a GP, and the accessibility of complete prescription information to healthcare practitioners.

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 extend detoxification follow-up beyond the medication course to explore continued substance use
Wider context from the report
“I heard that Mr Grady’s alcohol detoxification programme in January 2018 involved two appointments with his GP during which prescriptions for a seven day course of Chlordiazepoxide were issued. The GP was unaware that Alex was using any type of drugs. Given Mr Grady’s history of dependency on alcohol and benzodiazepines, a referral into the Drug and Alcohol service would have allowed for specialised support at that time of increased vulnerability. My concern is that if detoxification programmes are provided solely by the GP, adequate support is put in place. If a decision is made to manage the detoxification process within the GP practice, follow up appointments should extend beyond the date of the 7 day medication course so that questions around continued use of substances can be explored. ”
Source location
Alex Grady · Prevention of Future Deaths report
Page 2 · concerns
Open source report
1 Aug2019
Manchester South
Concerns raised2
1. Failure to enquire about patients’ current or continued illicit drug misuse
2. Failure to record enquiries about illicit drug misuse and patients’ responses
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Search the clinical system regularly for patients receiving regular opiate analgesia or Pregabalin who have a history of drug misuse.
  Stated by West Timperley Medical CentreStated completed
2. Action
  Contact identified patients to update records of their current illicit drug use.
  Stated by West Timperley Medical CentreStated in progress
3. Action
  Discuss illicit-drug-use recording requirements and clarify that stopped intravenous drug use does not establish cessation of all illicit drug use.
  Stated by West Timperley Medical CentreStated completed
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
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 individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record enquiries about illicit drug misuse and patients’ responses
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
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
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
15 Jun2018
Brighton and Hove
Concerns raised1
1. Failure to apply adequate safeguards when prescribing potentially dependence-forming or misused medication
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 19
1. Action
  Discuss discharge-information requirements with Emergency Department medical staff through regular governance meetings.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Increase staff awareness of frequent requests for small medication quantities as potential risk indicators.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
3. Action
  Audit records of patients receiving Zopiclone and review their prescribed quantities.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
1. Action
  Review high-risk prescribing records and remove online prescription-request access for weekly, controlled, dependency-forming and potentially abusive medicines.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
2. Action
  Provide protected administrative and clinical staff time to manage prescription requests.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
3. Action
  Discuss sharing the high-risk medication review protocol with a linked practice.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated in progress
4. Action
  Lower computer-alert thresholds for early prescription ordering and increase awareness of relevant alerts.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
5. Action
  Embed the high-risk drug review protocol with support from the Medication Management team.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated in progress
6. Action
  Ensure the new Practice Repeat Prescribing Policy covers current best practice.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated in progress
7. Action
  Audit Zopiclone prescribing to verify repeat-template intervals, doses and limits, and reduce some prescription amounts.
  Stated by North Laine Medical CentreStated completed
8. Action
  Remove online prescription requests for controlled drugs and drugs of potential abuse or dependence, following patient assessment.
  Stated by North Laine Medical CentreStated in progress
9. Action
  Change computer-system thresholds so early-order warnings appear one day before due dates and online ordering closes three days before due dates.
  Stated by North Laine Medical CentreStated completed
10. Action
  Add patients who overdose to the weekly prescription list.
  Stated by North Laine Medical CentreStated planned
11. Action
  Revise the practice prescribing policy using CCG pharmaceutical advice and discuss the updated policy in a whole-practice meeting.
  Stated by North Laine Medical CentreStated completed
12. Action
  Raise receptionist and GP awareness of patients ordering prescriptions too early, including when requested amounts appear small.
  Stated by North Laine Medical CentreStated completed
13. Action
  Review patients receiving controlled drugs and agree medication-reduction or cessation plans with them.
  Stated by North Laine Medical CentreStated in progress
14. Action
  Develop a computer-generated warning identifying patients with overdoses or suicide attempts when high-risk medicines are requested.
  Stated by North Laine Medical CentreStated in progress
15. Action
  Copy all GPs into reports of overdoses and other suicide attempts.
  Stated by North Laine Medical CentreStated completed
16. Action
  Code all overdoses and suicide attempts in the practice system.
  Stated by North Laine Medical CentreStated completed
AI-generated summary

Darren James CARRINGTON · 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

Darren James CARRINGTON died after collapsing with a fatal level of Zopiclone in his blood and did not recover. The inquest concluded that the death was misadventure, being an impulsive overdose while under the influence of alcohol. Concerns included the prescribing of potentially dependency-forming medication, excessive Zopiclone prescribing over 57 days, and the ability of receptionists and clinicians to override computer warnings and other safeguards.

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 apply adequate safeguards when prescribing potentially dependence-forming or misused medication
Wider context from the report
“The method of prescribing medication such as Zopiclone (in this case), Codeine, Morphine, Benzodiazepines etc. to patients which suggests that they either are or are very likely to be becoming dependent upon such medications or are misusing them. Examples of both the above would be too frequent requests for repeat prescriptions and information concerning a history of overdoses. The Inquest discussed whether circumstances, including those outlined above should trigger an automatic/mandatory medication review conducted with the patient; consideration of a different prescribing period and very careful monitoring of the online requests for repeat prescriptions. Alternatively, there could be a ban on the requests for repeat prescriptions with the repeats simply being issued for an appropriate period of time “automatically”. In this case as you will see from ████████ report, over twice the appropriate amount of Zopiclone was issued over a period of 57 days. The patient in question had Zopiclone present at a fatal level in his blood at the time of his collapse from which he never recovered. I remain very worried about these prescribing issues and about the fact that apparently receptionists and clinicians can override the warnings in the surgery’s computer system. I should like this to be carefully investigated and look forward to hearing with a response within the relevant time period. I realise that the situation may be exacerbated by GPs working part time and many part time practitioners being involved in the prescribing procedure as well as many receptionists being involved in it but if this is the trend then it seems to me the safeguards must be extended not made easier to override. The other ‘failsafe device’ is the dispensing pharmacist. When repeats are requested online there is a designated pharmacy. They receive emailed scripts. Their own systems should flag up cases of over or too frequent prescribing as well as other matters. ”
Source location
Darren James CARRINGTON · 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 discharge-information requirements with Emergency Department medical staff through regular governance meetings.

Verbatim wording from the response
“I am very sorry that Mr Carrington's GP, Sussex Partnership NHS Foundation Trust and Pavilions did not receive adequate information concerning the details of Mr Carrington’s mixed overdose and accept that this does not reflect good continuity of care. I can confirm that this has been fed back to ████████, Clinical Director for Emergency and Acute Medicine and to ████████, Consultant and Governance Lead for Emergency Medicine. ████████ have discussed these issues with all medical staff as part of the Emergency Department regular governance meetings to highlight the issues that arose from Mr Carrington’s attendances and the importance of ensuring that discharge letters contain sufficient detail.”

Source location
2018-0181-Response-from-Brighton-and-Sussex-University-Hospitals
Page 1 · response
Published 8 July 2018
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
Increase staff awareness of frequent requests for small medication quantities as potential risk indicators.

Verbatim wording from the response
“I can confirm that the following changes have been implemented at North Laine Surgery via a Practice Meeting attended by all staff:-”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Audit records of patients receiving Zopiclone and review their prescribed quantities.

Verbatim wording from the response
“I can confirm that the following changes have been implemented at North Laine Surgery via a Practice Meeting attended by all staff:-”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review high-risk prescribing records and remove online prescription-request access for weekly, controlled, dependency-forming and potentially abusive medicines.

Verbatim wording from the response
“• Records of all patients receiving weekly prescriptions have been reviewed and access to on-line requests have been removed.”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Provide protected administrative and clinical staff time to manage prescription requests.

Verbatim wording from the response
“• Arrangements have been made to ensure administrative and clinical staff have adequate, protected time to manage prescription requests.”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Discuss sharing the high-risk medication review protocol with a linked practice.

Verbatim wording from the response
“• Ongoing discussions with linked Practice around sharing high risk medication review protocol.”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Lower computer-alert thresholds for early prescription ordering and increase awareness of relevant alerts.

Verbatim wording from the response
“• Computer settings changed with a view to lower thresholds for flagging up early ordering of scripts and increased awareness around the potential significance of these and other alerts.”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Embed the high-risk drug review protocol with support from the Medication Management team.

Verbatim wording from the response
“Our Medication Management team are providing ongoing support. In particular, around embedding The High Risk Drug review protocol mentioned above, as well as ensuring that the new Practice Repeat Prescribing Policy covers current best practice.”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Ensure the new Practice Repeat Prescribing Policy covers current best practice.

Verbatim wording from the response
“Our Medication Management team are providing ongoing support. In particular, around embedding The High Risk Drug review protocol mentioned above, as well as ensuring that the new Practice Repeat Prescribing Policy covers current best practice.”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Audit Zopiclone prescribing to verify repeat-template intervals, doses and limits, and reduce some prescription amounts.

Verbatim wording from the response
“2. An audit of all patients on Zopiclone was carried out to ensure that limits and doses were correctly entered on the system. There was no evidence that any other patients had over-ordered or done so too early.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Remove online prescription requests for controlled drugs and drugs of potential abuse or dependence, following patient assessment.

Verbatim wording from the response
“3. Access to online requests for controlled drugs has been removed for all patients. Following discussion with the patient and their doctor, this may be restored if the patient is considered “low-risk”.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Change computer-system thresholds so early-order warnings appear one day before due dates and online ordering closes three days before due dates.

Verbatim wording from the response
“4. An investigation into online ordering and script generation by the computer system was conducted in conjunction with the practice IT co-ordinator. As a result, the timings were changed within the system so that warnings about scripts being ordered too early were changed from 7 to 1 day and ordering online from 10 to 3 days.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Add patients who overdose to the weekly prescription list.

Verbatim wording from the response
“5. Patients who overdose will be added to the weekly script list.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Revise the practice prescribing policy using CCG pharmaceutical advice and discuss the updated policy in a whole-practice meeting.

Verbatim wording from the response
“6. There has been an extensive revision of the practice prescribing policy incorporating suggestions from the CCG pharmaceutical adviser and we are having a practice meeting on 24th July to discuss further. We look forward to working with her again over the next year to improve further our systems.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Raise receptionist and GP awareness of patients ordering prescriptions too early, including when requested amounts appear small.

Verbatim wording from the response
“7. There has been a raised awareness of the potential of any patient to over-order medication, whether by accident or design.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review patients receiving controlled drugs and agree medication-reduction or cessation plans with them.

Verbatim wording from the response
“9. A whole practice meeting took place on 24th July to discuss the updated practice prescribing policy. Ongoing review of patients on controlled drugs ████████ ████████ will occur and a plan to reduce and/or stop agreed with the patient. This will complement what the practice already has put in place over the past 2 years in terms of reduction programmes for patients.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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 a computer-generated warning identifying patients with overdoses or suicide attempts when high-risk medicines are requested.

Verbatim wording from the response
“10. A further meeting is planned with the practice IT coordinator to highlight automatically patients who have taken an overdose when certain high-risk drugs are requested. We hope to have this in place shortly.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Copy all GPs into reports of overdoses and other suicide attempts.

Verbatim wording from the response
“Action plan following meeting held on 22nd May which have been implemented by the practice.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 3 · response
Published 8 July 2018
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
Code all overdoses and suicide attempts in the practice system.

Verbatim wording from the response
“Action plan following meeting held on 22nd May which have been implemented by the practice.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 3 · response
Published 8 July 2018
Open published response
8 May2018
Gloucestershire
Concerns raised1
1. Failure to consider concurrent use of additional fentanyl and illicit medication and its effects
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Establish opioid-user ward management guidelines covering prescribing advice and specialist input.
  Stated by Gloucestershire Hospitals NHS Foundation TrustStated completed
AI-generated summary

Jonathan Earp · 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

Jonathan Earp died at Gloucester Royal Hospital on 10 July 2017 from the effects of prescribed and non-prescribed drugs. Concerns included the management and disposal of Fentanyl patches and the possibility that additional Fentanyl was taken alongside illicit drugs without staff considering the combined effects.

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 consider concurrent use of additional fentanyl and illicit medication and its effects
Wider context from the report
“I heard during the inquest that Mr Earp had been prescribed Fentanyl which was administered by way of transdermal patches. Mr Earp repeatedly requested additional patches however there was no evidence that all of the "unsent" patches had been returned to the nursing staff or appropriately discarded. The clinical staff believed that Mr Earp was accessing illicit drugs when he left the ward, however there was no evidence that staff considered that he may have been taking additional Fentanyl and illicit medication, and the effect this could have. ”
Source location
Jonathan Earp · 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
Establish opioid-user ward management guidelines covering prescribing advice and specialist input.

Verbatim wording from the response
“Review policy and flowchart on “OPIOID USERS ON THE WARD – MANAGEMENT GUIDELINES” | These guidelines have been drawn up to advise doctors, nurses and pharmacists on managing patients who have an opioid pain management pathway, and to provide further advice on prescribing from the Acute Pain Management team and/or providers of the Drug dependency service. | Consultant for Acute Pain Management | July 2018 | Complete”

Source location
2018-0135-Response-by-Gloucestershire-Hospitals-NHS-Trust
Page 3 · response
Published 1 July 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to extend detoxification follow-up beyond the medication course to explore continued substance use

Concerns raised2

Failure to enquire about patients’ current or continued illicit drug misuse

Failure to record enquiries about illicit drug misuse and patients’ responses

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to apply adequate safeguards when prescribing potentially dependence-forming or misused medication

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.19

Concerns raised1

Failure to consider concurrent use of additional fentanyl and illicit medication and its effects

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 3

Actions described in response 19

Actions described in response 1