7 Feb 2023 Ania Sohail · Prevention of Future Deaths report Manchester North
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Concerns raised 2
Lack of online pharmacy information sharing with patients’ GPs View source Failure to prevent contraindicated prescribing across online and other prescribers View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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AI-generated summary
Ania Sohail · 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
Ania Sohail collapsed on 19 June 2021 after ingesting Propranolol tablets she had obtained from multiple online pharmacies and died later that day from Propranolol toxicity. The principal concerns included the lack of integrated information sharing between online pharmacies and prescribers, ineffective and poorly documented searches, inadequate post-leave assessment and care planning, and insufficiently auditable observation records.
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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 online pharmacy information sharing with patients’ GPs
Wider context from the report “(2) There is no requirement for the on-line pharmacies to share information with the patient’s GP . This means that, in the absence of the patient’s consent to share information, the online prescriber is reliant on the accuracy and truthfulness of the history provided by the patient .
” Source location Ania Sohail · Prevention of Future Deaths report
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 prevent contraindicated prescribing across online and other prescribers
Wider context from the report “(3) Lack of information sharing also creates a risk that a GP or Pharmacist Prescriber may unwittingly prescribe a medication that is contraindicated with a medication that has been dispensed through an on-line pharmacy .
” Source location Ania Sohail · Prevention of Future Deaths report
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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 NHS England has no jurisdiction over private healthcare provision, including private online prescribing services.
Verbatim wording from the response “NHS England has no jurisdiction over private provision. Private providers would need a very good reason to breach a patient’s refusal to share their information as they are legally obliged to safeguard sensitive information under the General Data Protection Regulation. The General Pharmaceutical Council has provided information to online pharmacies on Providing medicines online, which is available at: Online Pharmacy Services (pharms.com)” Source location Response from Department of Health and Social Care
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3 Aug 2022 Kellum Paul Thomas · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Delays in sending outpatient letters containing important clinical information View source
This report raised 3 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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AI-generated summary
Kellum Paul Thomas · 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
Kellum Paul Thomas, aged thirteen, collapsed at home on 9 June 2021 and died after a cardiac arrest caused by ventricular tachycardia deteriorating into ventricular fibrillation. Concerns included an 18-month gap without a functioning REVEAL heart-monitoring device, delayed replacement processes, and a significantly delayed outpatient letter containing medication and investigation information. The report also identified stretched team capacity and resources and stated that necessary actions to address these issues were not confirmed.
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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 Delays in sending outpatient letters containing important clinical information
Wider context from the report “2. Kellum’s outpatient letter from ████████ to both the GP and to Nottingham University Hospitals NHS Trust (where shared care was provided) was very delayed , with the outpatient appointment completed in March 21, and the letter not reaching its destinations until mid June 21, after Kellums death . This letter contained important information re a change in medication dosage and a request for NUH to arrange a further investigation. Again this issue appeared to be one of team capacity and resources.
” Source location Kellum Paul Thomas · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to notify the person's GP of prescribed drugs View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission Department of Health and Social Care General Medical Council General Pharmaceutical Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
General Pharmaceutical Council
Publish guidance for pharmacist prescribers on sharing prescribing information with people’s prescribers and other care professionals.
View source
Care Quality Commission
Inspect online providers’ management of medicines, prescriptions, consent, identity checks, information sharing, governance and staff safety training.
View source
Care Quality Commission
Publish guidance requiring providers to inform patients’ GPs about prescribed medications and assess safety when patients decline information sharing.
View source
Department of Health and Social Care
Work with healthcare regulators on digital healthcare provision.
View source
Department of Health and Social Care
Review the UK legislative position on digital healthcare and identify regulatory gaps.
View source See 2 more actions
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Jamie Francis O'Connor · 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
Jamie O’Connor was found deceased in the garden of his home in Leicester on 14 October 2018 after his mother became concerned that he was not responding to phone calls. The report identified concerns about online prescribing, including the lack of central tracking, limited information sharing with GPs, no required face-to-face consultation, limited questionnaires, patients requesting specific drugs, and limited regulation; the inquest concluded that this was a drug-related death and recorded the cause as ████████ toxicity.
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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 notify the person's GP of prescribed drugs
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Source location Jamie Francis O'Connor · 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 Publish guidance for pharmacist prescribers on sharing prescribing information with people’s prescribers and other care professionals.
Verbatim wording from the response “We have also published ‘In practice: Guidance for pharmacist prescribers’, which set out the key areas we expect pharmacist prescribers to consider when applying the standards to their prescribing practice. The guidance states that prescribing information should be shared with the person’s prescriber, or others involved in their care, so the person receives safe and effective care.” Source location 2021-0363-Response-from-GPC_Published
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 Inspect online providers’ management of medicines, prescriptions, consent, identity checks, information sharing, governance and staff safety training.
Verbatim wording from the response “For those providers who fall within the CQC’s scope of regulation we inspect against the regulations using an inspection framework. All providers must comply with the regulations as set out in The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (RAR 2014). The regulations that would be most relevant to any reviews around online providers, would include, but not be limited to, the following:” Source location 2021-0363-Response-from-CQC_Published
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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 guidance requiring providers to inform patients’ GPs about prescribed medications and assess safety when patients decline information sharing.
Verbatim wording from the response “CQC has published guidance for providers¹. The guidance describes the expectations of providers to ensure a patient’s GP is informed of prescribed medications from their service. We also expect that should the patient decline to consent for the sharing” Source location 2021-0363-Response-from-CQC_Published
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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 Work with healthcare regulators on digital healthcare provision.
Verbatim wording from the response “The Department is working with other healthcare regulators including the General Medical Council and their equivalents in Scotland, Wales and Northern Ireland in the area of digital healthcare provision. As a result, a review of the UK’s legislative position was undertaken and gaps identified. These included cases involving inappropriate prescribing and a lack of checks with the patient’s GP before prescribing. There were also concerns about the absence of pharmacy records of medicines dispensed by other pharmacies. The Department and healthcare regulators are also working together to review prescribing by private prescribers in relation to controlled drugs.” Source location Response from DHSC
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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 Review the UK legislative position on digital healthcare and identify regulatory gaps.
Verbatim wording from the response “The Department is working with other healthcare regulators including the General Medical Council and their equivalents in Scotland, Wales and Northern Ireland in the area of digital healthcare provision. As a result, a review of the UK’s legislative position was undertaken and gaps identified. These included cases involving inappropriate prescribing and a lack of checks with the patient’s GP before prescribing. There were also concerns about the absence of pharmacy records of medicines dispensed by other pharmacies. The Department and healthcare regulators are also working together to review prescribing by private prescribers in relation to controlled drugs.” Source location Response from DHSC
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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 Online consultations and prescribing without face-to-face assessment can be safe where appropriate safeguards, history-taking, GP engagement and monitoring exist.
Verbatim wording from the response “Through our regulation of independent online primary medical services, CQC has identified gaps in the regulatory framework for independent online providers. We continue to have concerns about safety gaps, which generally align to those you have identified. We do however recognise there are benefits in the provision of online services, and for consultations and prescribing without the need for a face to face consultation where there are appropriate safeguards in place. These include history taking, engagement with the registered GP, and monitoring, as well as a risk assessing those medicines that are prescribed by a service. Our specific concerns are in the following areas:” Source location 2021-0363-Response-from-CQC_Published
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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 Systems for accessing and sharing prescribing and dispensing information are outside the respondent’s remit.
Verbatim wording from the response “Systems for accessing and sharing information about the prescribing and dispensing of medicines are outside the GMC’s remit. However, we strongly agree that effective systems are vital to ensuring safe and effective care.” Source location 2021-0363-Response-from-GMC_Published
Open published response
Concerns raised 2
Failure of doctors considering opiate prescriptions to contact the registered GP View source Failure of dispensing pharmacists to contact the registered GP when checking prescription appropriateness View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Care Quality Commission
Inspect each registered online provider identified from the inquest and review their medication-prescribing management processes.
View source
Care Quality Commission
Submit proposals to DHSC for legislative changes addressing regulatory safety gaps in independent online primary care services.
View source
Care Quality Commission
Share key learning and practice points from the inquest with relevant providers and stakeholders.
View source
Care Quality Commission
Continue using enforcement powers to require improvements when online providers fail to meet regulatory requirements.
View source
Care Quality Commission
Publish guidance setting expectations for providers to inform patients’ GPs about prescribed medicines and assess safety when information sharing is declined.
View source See 2 more actions
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AI-generated summary
Katie Emma Corrigan · 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
Katie Emma Corrigan had a history of chronic pain, anxiety and depression, and developed an addiction to pain-relieving medication. She obtained medication from multiple sources, and the report raised concerns that doctors, pharmacists and alert systems did not prevent her from obtaining sufficient opiate medication to cause her death.
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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 doctors considering opiate prescriptions to contact the registered GP
Wider context from the report “The GP who gave evidence at the inquest, Dr ████████ from Bodriggy Health Centre in Hayle, stated that she had never been contacted by any other doctor considering the prescription of opiate or other medication to Mrs Corrigan . She was able to procure the medication in sufficient quantities first to require an emergency admission to hospital and latterly to result in her death.
Similarly, the registered GP was not contacted by any dispensing pharmacist checking whether the prescription was appropriate.
After Dr ████████ became aware of the two on-line pharmacies who had dispensed the medication to Mrs Corrigan that led to her admission into hospital, she attempted to raise an alert through NHS England, in order that the unsuitability of prescribing opiate medication to Mrs Corrigan could be raised with clinicians. This was sent out regionally but Dr ████████ has since been advised there is no formal procedure for circulating Patient Alerts to pharmacies on a national level.
I am further given to understand that non NHS contacts would only receive a redacted version of the alert in any event.
What seems clear is that the alert proved ineffective in preventing Mrs Corrigan from improperly obtaining sufficient quantities of opiate medication to result in her death.
” Source location Katie Emma Corrigan · Prevention of Future Deaths report
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 of dispensing pharmacists to contact the registered GP when checking prescription appropriateness
Wider context from the report “The GP who gave evidence at the inquest, Dr ████████ from Bodriggy Health Centre in Hayle, stated that she had never been contacted by any other doctor considering the prescription of opiate or other medication to Mrs Corrigan. She was able to procure the medication in sufficient quantities first to require an emergency admission to hospital and latterly to result in her death.
Similarly, the registered GP was not contacted by any dispensing pharmacist checking whether the prescription was appropriate .
After Dr ████████ became aware of the two on-line pharmacies who had dispensed the medication to Mrs Corrigan that led to her admission into hospital, she attempted to raise an alert through NHS England, in order that the unsuitability of prescribing opiate medication to Mrs Corrigan could be raised with clinicians. This was sent out regionally but Dr ████████ has since been advised there is no formal procedure for circulating Patient Alerts to pharmacies on a national level.
I am further given to understand that non NHS contacts would only receive a redacted version of the alert in any event.
What seems clear is that the alert proved ineffective in preventing Mrs Corrigan from improperly obtaining sufficient quantities of opiate medication to result in her death.
” Source location Katie Emma Corrigan · 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 Inspect each registered online provider identified from the inquest and review their medication-prescribing management processes.
Verbatim wording from the response “CQC has inspected each of the registered online providers that you identified from the inquest into Ms Corrigan’s death that Ms Corrigan may have used. At each inspection, management processes for prescribing medications were reviewed and if concerns were identified we took regulatory action against the provider or the inspection report shared details of the areas needing improvement.” Source location 2021-0045-Response-from-CQC-Redacted
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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 Submit proposals to DHSC for legislative changes addressing regulatory safety gaps in independent online primary care services.
Verbatim wording from the response “Since January 2021 CQC has been in discussions with, and submitted, proposals for legislative changes to the Department of Health and Social Care (DHSC), to improve CQC’s ability to take action against independent providers of online primary care services that are putting people’s lives at risk. In particular, we are looking to address safety gaps in the following areas:” Source location 2021-0045-Response-from-CQC-Redacted
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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 Share key learning and practice points from the inquest with relevant providers and stakeholders.
Verbatim wording from the response “Where CQC identifies that regulations are not being met, we use our enforcement powers to require improvements to be made. We continue to do this and will share key learning and practice points from the inquest into the death of Katie Corrigan.” Source location 2021-0045-Response-from-CQC-Redacted
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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 Continue using enforcement powers to require improvements when online providers fail to meet regulatory requirements.
Verbatim wording from the response “Where CQC identifies that regulations are not being met, we use our enforcement powers to require improvements to be made. We continue to do this and will share key learning and practice points from the inquest into the death of Katie Corrigan.” Source location 2021-0045-Response-from-CQC-Redacted
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 Publish guidance setting expectations for providers to inform patients’ GPs about prescribed medicines and assess safety when information sharing is declined.
Verbatim wording from the response “CQC has published guidance for providers¹. The guidance describes the expectations of providers to ensure a patient’s GP is informed of prescribed medications from their service. We also expect that should the patient decline to consent for the sharing of such information to take place, the prescriber should consider whether it is still safe to continue and accept the full responsibility for their actions and act in line with GMC prescribing guidance.” Source location 2021-0045-Response-from-CQC-Redacted
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13 Nov 2019 Dorothy June MACEY · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure to share and escalate delayed antibiotic treatment information View source
This report raised 10 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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AI-generated summary
Dorothy June MACEY · 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
Dorothy June MACEY sustained leg injuries when her legs went through a glass door and was later discharged home with district nurse dressing care. Antibiotics prescribed in September were not received promptly, and concerns were raised about wound assessment, information sharing, record-keeping, sepsis checks, medication monitoring, care planning and a missed visit. She was admitted to hospital for sepsis on 28 September 2018, developed gangrene in her left lower leg, and died at Medway Maritime Hospital on 7 October 2018.
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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 share and escalate delayed antibiotic treatment information
Wider context from the report “(1) Protocol required district nurses to photograph the leg wounds to assist in the assessment and this was not done on any of the visits. I heard evidence that photographs on the patient electronic record cannot be accessed remotely on home visits limiting the shared information that should be available to conduct an assessment.
(2) District nurses did not share information with the GP when it was established that there had been a delay in the prescribed antibiotic treatment regime, and this was not escalated within the team.
(3) Incomplete recording- The district nurse electronic care and treatment records on iNurse were:
a) very brief and did not contain information necessary to have a comprehensive assessment or understanding of deterioration or improvement in her condition
b) difficult to access remotely and showed limited information, therefore the previous nurse attendance could not be seen on particular visits. Evidence was that the record was not accessed prior to the visit on 24th September and the delay in the treatment regime was not understood when antibiotics were requested on that day.
(4) A sepsis pathway check was completed on 20th September. This was not completed when antibiotics were requested on 24th September. There is a concern that developing sepsis may be missed in a deteriorating patient.
(5) There was no updated care plan in place for her leg dressings. District nurse support staff changed the type of leg dressings without approval of the qualified nurses, evidence was heard that this should not be done without discussion.
(6) Medication administration charts completed by carers were incomplete. The antibiotic administration was not checked despite previous issues with the delay in the treatment regime becoming known to district nurses on 20th September. This record was shared with or escalated to the GP for advice when there was a lack of improvement in her condition.
(7) A visit required for 28th September was incorrectly scheduled for 1st October and was not picked up within the Missed Visit protocol in place.
” Source location Dorothy June MACEY · Prevention of Future Deaths report
Open source report
4 Jul 2019 Miriam Tighe · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of information sharing between GPs and psychiatrists about sedative and antipsychotic medication decisions 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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Miriam Tighe · 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
Miriam Tighe became a resident of Edge Hill Residential Home in August 2016 and later received hospital and residential nursing care before passing away on 28 February 2017. The report identified concerns that promazine and other sedative or antipsychotic medication continued to be prescribed and administered despite advice to stop promazine, and that communication between GPs and a psychiatrist was insufficient, leading to unsafe prescribing. The investigation recorded that her death followed naturally occurring disease, with high levels of sedation and immobility in the preceding months worsening her frailty.
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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 information sharing between GPs and psychiatrists about sedative and antipsychotic medication decisions
Wider context from the report “Promazine was sought by the home manager at Edge Hill Residential Home and prescribed by the GPs at Royton & Crompton family practice after ████████ (Psychiatrist working in the Memory Clinic (part of Pennine Care NHS Foundation Trust)) had advised that such medication be stopped on the 16th November 2016 and, again on the 16th December 2016. On both occasions, promazine continued to be prescribed by the GP and continued to be administered under the control of the manager at Edge Hill Residential Home. In the event, I found that Miriam Tighe had been over-sedated during her time as a resident at Edge Hill Residential Home. The psychiatrist had recommended alternative sedative and antipsychotic medication, which was also administered to Miriam Tighe. It was clear that the GPs and the Psychiatrist were not aware of decisions being made by each other in October to December 2016 , which led to unsafe prescribing of sedatives and antipsychotic medication .
” Source location Miriam Tighe · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to independently verify patients’ concurrent opiate replacement therapy and prescribing organisation View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
NHS England
Contact the service lead and request reviews of GP-data collection, verification, and reliable information sharing with registered GPs.
View source
NHS England
Write to Staffordshire GP practices about the inquest risks, considering other agencies' opiate prescribing, and alerting the clinic when patients are registered elsewhere.
View source
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AI-generated summary
Andrew Peter McCall · 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
Andrew Peter McCall was found face down and unresponsive in supported living accommodation on 18 September 2018. A post-mortem examination and toxicology attributed his death to gastric aspiration associated with Pregabalin and Methadone use. The report raised concern that his GP was unaware of his Methadone prescription and could therefore prescribe medications that might be unsuitable or potentially harmful.
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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 independently verify patients’ concurrent opiate replacement therapy and prescribing organisation
Wider context from the report “The evidence revealed a clear pattern of “medication seeking behaviour” with his GP to obtain additional amounts of Pregabalin. The evidence also showed that his GP was not aware that he was on a current Methadone script. The “One Recovery” clinic operated a system which was dependent upon the service user declaring which GP practice they were registered with. This was not checked or verified independently and therefore concern must exist that the GP may be unaware that a patient is on an opiate replacement regime, prescribed by another organisation , and may therefore prescribe medications which may not be suitable and which may potentially be harmful . It is suggested that, where patients are prescribed medication as part of “opiate replacement therapy”, GPs have the means to check the details and the organisation providing such a service. This puts in place a more robust system to ensure that the current GP is fully aware of the treatment programme.
” Source location Andrew Peter McCall · 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 Contact the service lead and request reviews of GP-data collection, verification, and reliable information sharing with registered GPs.
Verbatim wording from the response “Dr Kenneth Deacon, Medical Director for System Improvement and Professional Standards (Midlands) will:” Source location 2019-0228-Response-by-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 Write to Staffordshire GP practices about the inquest risks, considering other agencies' opiate prescribing, and alerting the clinic when patients are registered elsewhere.
Verbatim wording from the response “Write to all GP practices within Staffordshire:
- making them aware of the inquest findings, and the risks this highlights;
- reminding them of the importance of considering whether other agencies might be prescribing opiate replacements; and
- asking them to alert the clinic directly if they receive information relating to a patient not registered at the practice (so the correct practice can be identified quickly).” Source location 2019-0228-Response-by-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 NHS England is neither commissioner nor regulator of these substance misuse services and has no direct responsibility for them.
Verbatim wording from the response “Although NHS England is neither the commissioner or regulator of these services, and have no direct responsibility for them, we recognise the importance of the concerns you have raised, and are taking the following action:” Source location 2019-0228-Response-by-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 Local Authority, rather than NHS England or the Clinical Commissioning Group, commissions these substance misuse services.
Verbatim wording from the response “In this case the service is provided by One Recovery Clinic, in conjunction with North Staffordshire Combined Healthcare NHS Trust. The lead provider is Addiction Dependency Solution. Substance misuse services are commissioned by the Local Authority, not NHS England or the Clinical Commissioning Group.” Source location 2019-0228-Response-by-NHS-England
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14 Mar 2018 Peter STOJILJKOVIC · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to communicate with community GPs before discharge about ongoing melatonin prescribing View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Peter STOJILJKOVIC · 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
Peter Stojiljkovic was discharged from hospital on 9 June 2017 after being prescribed melatonin and was later found suspended by a ligature at his home on 22 July 2017. The concerns included poor communication between the hospital, GP and Peter about community prescribing, differing prescribing policies, the complexity of prescribing guidance, and the possibility that he would need to obtain melatonin from unlicensed sources. There was also no evidence of communication with the GP before discharge to support a smooth transition into the community.
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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 communicate with community GPs before discharge about ongoing melatonin prescribing
Wider context from the report “1. The deceased had been prescribed melatonin whilst an in-patient. The inquest heard that post his discharge communication between the hospital; GP and Mr Stojiljkovic was such that he was unaware that his GP was prepared to prescribe melatonin in the community ;
2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists. It was unclear why Stockport CCG took a different approach to other CCGs
3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty.
4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it. This created a risk that he would have to access the drug from unlicensed sources.
5. It was known whilst he was an in-patient that difficulties with prescribing melatonin in the community would arise. There was no evidence of any attempt to communicate with the GP prior to discharge to ensure a smooth discharge into the community.
” Source location Peter STOJILJKOVIC · 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 the case with the practice to identify further learning.
Verbatim wording from the response “1. We accept that from the information in the letter that there has been a breakdown in communication with the patient. You have written to the practice and we assume they will respond to that issue. However, our Medical Director will review the case with the practice to identify any further learning.” Source location 2018-0077-Response-by-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 Raise how medication provision at discharge was handled with Pennine Care and identify required improvements.
Verbatim wording from the response “4. We would not expect anybody to be told that they should access medication via the internet and we will discuss this with Pennine Care, and identify any further action that needs to be taken in respect of this finding. However, as you have written to Pennine Care I assume that they will respond to you directly on this issue. In addition, we will raise the issue of how the provision of medication at discharge was handled by Pennine Care, and again identify any improvements that they need to make.” Source location 2018-0077-Response-by-NHS-England
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27 Feb 2018 Rachel Holly Edwards · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Failure to reliably notify GPs of discharge medication types and quantities 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
Rachel Holly Edwards · 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
Rachel Holly Edwards died on 8 May 2017 after an overdose of multiple prescription medicines, following a period of severe and unbearable pain. Concerns identified at the inquest included unclear quantities of discharge medication, inadequate communication of prescriptions to her GP, record-keeping weaknesses, and the absence of a formal patient advocate system to support her when pain-management news and treatment administration increased her hopelessness.
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× 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 reliably notify GPs of discharge medication types and quantities
Wider context from the report “The first concern regards the prescription of discharge medication, sharing that information with the GP and record keeping.
It was known that Rachel was at risk of stockpiling medication as in the Serious Incident Requiring Investigation (SIRI) report it is noted that a request made on the 7th March 2017 by her treating doctor, for the disposal of her stocks of medication had not been actioned.
Further, Rachel's care co-ordinator specifically recalled asking Rachel if she had stockpiled any medication after her discharge on the 29th March 2017, as he had identified this to be a risk.
It is therefore a concern that according to Rachel's notes that on the day of her discharge she was supplied with 14 days of medication. This was described in evidence as ‘standard practice’.
That said, some consideration appears to have been given to the quantity of some medication issued, as on closer inspection of the notes it was identified that specifically in relation to Tramadol Rachel had been prescribed this for only a 7-day period.
However, there was no clear record within the notes if her other medication had actually been issued in 7 or 14 days amounts.
Such confusion over the actual quantities of medication issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a view to self-harm, is of obvious concern.
Also of concern was evidence given by a senior consultant that there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands. Obviously, it is crucial that this information is readily available to a GP in all cases, to ensure that the over-prescription of medicines to a recently discharged patient does not occur. Evidence was heard that in order for Woodlands to notify a GP it is necessary for a staff member to e-mail the relevant practice, providing details of the prescriptions that had been made. This information would then have to be subsequently included in the patient's local record before it was available to the treating GP. Obviously, any system requiring such physical human input can be prone to failure and in the consultant's own words it was a recognised ‘point of weakness in the system’ .
” Source location Rachel Holly Edwards · 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 Plan the technical changes required to notify GPs electronically about prescribed discharge medication.
Verbatim wording from the response “You raised the matter that there was no automated notification to the service user’s GP of the type and amounts of prescribed medication issued at the point of discharge. This information is crucial to help reduce the potential of over prescribing. You heard that the current process involves human action through use of emails.” Source location Response from Norfolk and Suffolk NHS Foundation Trust
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28 Mar 2017 Olive DAYNES · Prevention of Future Deaths report South Lincolnshire
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Concerns raised 1
Failure to communicate hospital advice, medication changes and increased INR levels to the GP in time View source
Linked response
United Lincolnshire Teaching Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
United Lincolnshire Teaching Hospitals NHS Trust
Send electronic inpatient discharge letters to the appropriate GP practice within 24 hours of discharge.
View source
United Lincolnshire Teaching Hospitals NHS Trust
Issue and recirculate standards for communicating test results between secondary and primary care.
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United Lincolnshire Teaching Hospitals NHS Trust
Circulate an organisation-wide patient safety bulletin on antibiotic-related anticoagulation interactions and timely communication.
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United Lincolnshire Teaching Hospitals NHS Trust
Write to the lead clinicians of all three Accident and Emergency departments about the concerns and required timely communication.
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United Lincolnshire Teaching Hospitals NHS Trust
Develop electronic Accident and Emergency documentation enabling direct electronic transmission of clinical information to patients’ GPs.
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AI-generated summary
Olive DAYNES · 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
Olive Daynes, described as an 86-year-old lady, presented to hospital with an altered mental state and a suspected fall after earlier treatment for painful or sore legs and ulcers. The report identified concerns about Warfarin being prescribed with antibiotics, inadequate monitoring, communication between the hospital and GP surgery, and a subsequent INR increase to over 9 before she passed away.
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× 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 communicate hospital advice, medication changes and increased INR levels to the GP in time
Wider context from the report “1. On 28/12/2015 Mrs. Daynes was admitted to Accident and Emergency at the Pilgrim Hospital, Fishtoft, and Boston following painful / sore legs/ulcers.
2. Her INR was recorded at 3.6, her medication changed and the matter was referred back to the GP.
3. A doctor from the GP's surgery saw Mrs Daynes the next day on 29th December 2015 but was unaware of the advice provided by the hospital, change in medication or increased IRN levels .
4. The hospital wrote to the surgery and the letter arrived on 4/2/2016 (date stamp verified by the Coroner).
5. In the intervening period the patients INR increased to over 9 and she passed away on 5/1/2016.
” Source location Olive DAYNES · 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 Send electronic inpatient discharge letters to the appropriate GP practice within 24 hours of discharge.
Verbatim wording from the response “5. In order to prevent similar deaths in the future, the discharge letter is sent by electronic means to the appropriate GP email address of the appropriate GP surgery.” Source location Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
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 Issue and recirculate standards for communicating test results between secondary and primary care.
Verbatim wording from the response “7. In 2016 the Trust and the Lincolnshire Local Medical Committee issued a document setting the standards and principles by which test results should be communicated by secondary and primary care. I enclose a copy of this document which was sent to all clinicians within ULHT. This has been circulated again to remind colleagues of their responsibilities.” Source location Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
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 Circulate an organisation-wide patient safety bulletin on antibiotic-related anticoagulation interactions and timely communication.
Verbatim wording from the response “8. With reference to the prescription of antibiotics which led to the abnormal anticoagulation for Mrs Daynes, a Patient Safety Bulletin highlighting this interaction and the need for effective and timely communication has been circulated across the organisation. I attach a copy of this. I have written to the Lead Clinicians of our 3 Accident and Emergency Departments highlighting the concerns you have raised as well as the need to ensure appropriate and timely communication.” Source location Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
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 Write to the lead clinicians of all three Accident and Emergency departments about the concerns and required timely communication.
Verbatim wording from the response “8. With reference to the prescription of antibiotics which led to the abnormal anticoagulation for Mrs Daynes, a Patient Safety Bulletin highlighting this interaction and the need for effective and timely communication has been circulated across the organisation. I attach a copy of this. I have written to the Lead Clinicians of our 3 Accident and Emergency Departments highlighting the concerns you have raised as well as the need to ensure appropriate and timely communication.” Source location Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
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 electronic Accident and Emergency documentation enabling direct electronic transmission of clinical information to patients’ GPs.
Verbatim wording from the response “9. At present electronic communication between the A & E Department and Primary Care is not available to the Trust. However, we are aware of an impending requirement to move to this. We are therefore in the process of developing electronic documentation in the A & E Department which will also enable direct electronic communication of clinical information to the patients GP. Our ability to progress this is influenced by a range of other actions currently being rolled out including:” Source location Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
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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 Electronic A&E-to-GP communication cannot yet be implemented because competing Trust-wide electronic systems and IT upgrades constrain progress.
Verbatim wording from the response “9. At present electronic communication between the A & E Department and Primary Care is not available to the Trust. However, we are aware of an impending requirement to move to this. We are therefore in the process of developing electronic documentation in the A & E Department which will also enable direct electronic communication of clinical information to the patients GP. Our ability to progress this is influenced by a range of other actions currently being rolled out including:” Source location Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.