Recurring concern

Failure to apply overdose-risk safeguards to medication prescribing

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First reported 15 Jan 2015•Latest report 27 Oct 2025

Definition

What this concern includes

Includes prescribing-process controls specifically intended to identify and respond to a patient's overdose history or material overdose risk, including mandatory clinical review before issuing prescriptions, scrutiny of repeat prescriptions, use of relevant overdose information and proportionate restrictions or supervision of prescribing.

Not included

Excludes general medication-prescribing errors, medication review or quantity-control failures where no overdose history or material overdose risk is part of the asserted unsafe condition.
Excludes medication administration, dispensing, storage or supply failures occurring after a safe prescribing decision unless the prescribing safeguard itself was deficient.
Excludes generic record-keeping, communication, training or alert-system deficiencies unless they directly impair overdose-risk safeguards in medication prescribing.
Excludes treatment of an overdose and broader self-harm or suicide-risk management where no medication-prescribing control is identified.

Reports: 12
Individual concerns: 16
Date range: 2015–2025
Stated actions: 26

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.

Department of Health and Social Care3

NHS England2

Addison House Surgery1

Ashford and St Peter'S Hospitals NHS Foundation Trust1

Axminster Medical Practice1

Bedfordshire Hospitals NHS Foundation Trust1

Daynight Pharmacy (Macklin Street)1

Devon Partnership NHS Trust1

Epsom and St Helier University Hospitals NHS Trust1

Frimley Health NHS Foundation Trust1

General Medical Council1

Hampshire and Isle of Wight Constabulary1

Heathview Medical Practice1

Macklin Street Surgery1

NHS Derby and Derbyshire Integrated Care Board1

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.

23 May2019
Central Hampshire
Concerns raised1
1. Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol
This report raised 5 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
  Disseminate relevant prescribing guidance extracts to support safe prescribing and patient safety.
  Stated by General Medical CouncilStated completed
2. Action
  Refer information about the private GPs to an Assistant Registrar to determine whether the investigation threshold is met.
  Stated by General Medical CouncilStated completed
3. Action
  Explore Graphnet as an integrated care record providing organisations read-only access to legal status, risks and contemporaneous care plans.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progress
Respondent positions 2
1. Position
  Existing GMC prescribing guidance, when followed, is considered sufficient to ensure safe practice and protect patient safety.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
1. Position
  Existing prescribing guidance is considered sufficient to ensure safe prescribing and protect patient safety when followed.
  Stated by General Medical CouncilExisting arrangements considered sufficient
AI-generated summary

Sasha Sabrina FORSTER · 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

Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.

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 access to relevant psychiatric and prescribing history when prescribing Propranolol
Wider context from the report
“Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart. In each consultation Sasha: - requested Propranolol, on the basis that it was currently being prescribed to her for anxiety; - revealed a limited history of mental health issues; - failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol. Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol. Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it. ”
Source location
Sasha Sabrina FORSTER · 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
Disseminate relevant prescribing guidance extracts to support safe prescribing and patient safety.

Verbatim wording from the response
“With regards to prescribing, the GMC’s guidance is clear that a doctor must only prescribe when they have adequate knowledge of the patient’s health. This will involve making an assessment, together with the patient, of their condition and having, or taking, an adequate history.”

Source location
Sasha-Forster-R2019-01694
Page 1 · response
Published 2 August 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
Refer information about the private GPs to an Assistant Registrar to determine whether the investigation threshold is met.

Verbatim wording from the response
“Conduct of individual doctors When a doctor fails to adhere to our ethical guidance the GMC must establish whether our threshold for investigation has been met; namely, whether the doctor’s conduct, if proven, is capable of amounting to impaired fitness to practise to a degree warranting action on their registration.”

Source location
Sasha-Forster-R2019-01694
Page 2 · response
Published 2 August 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
Explore Graphnet as an integrated care record providing organisations read-only access to legal status, risks and contemporaneous care plans.

Verbatim wording from the response
“There is a long term goal to create a platform that will allow NHS organisations to have read only access to key information pulled from a service user’s internal record keeping platforms. Graphnet is currently being explored to provide an integrated care record across Surrey. This will potentially be able to show that a person is currently detained in hospital allowing other organisations to see their legal status, as well as associated risks. Were a system such as this in place in early 2017 this would have allowed staff at the acute hospitals to view Sasha’s legal status and contemporaneous care plans; this would have assisted their decision making and meant that the system would have had read only access to the notes from her interactions with other services.”

Source location
Sasha-Forster-R2019-01692
Page 4 · response
Published 2 August 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing GMC prescribing guidance, when followed, is considered sufficient to ensure safe practice and protect patient safety.

Verbatim wording from the response
“Turning to the matter of concern relating to the prescribing of propranolol. My officials have made enquiries and I am aware that the General Medical Council (GMC) has responded to you to explain that its prescribing guidance² is clear that a doctor must only prescribe when they have adequate knowledge of the patient’s health. This should involve making an assessment together with the patient of their condition and having, or taking, an adequate history. A patient’s consent to contact their GP should be sought if more information, or confirmation of the information available, is needed before prescribing. The GMC is confident that its guidance, when followed, ensures safe practice and protects patient safety.”

Source location
Sasha-Forster-R2019-0169
Page 2 · response
Published 2 August 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing prescribing guidance is considered sufficient to ensure safe prescribing and protect patient safety when followed.

Verbatim wording from the response
“I have enclosed extracts of the relevant sections of our ethical guidance at Annex A of this letter; and, we consider that this guidance, when followed, ensures safe prescribing and protects patient safety.”

Source location
Sasha-Forster-R2019-01694
Page 2 · response
Published 2 August 2019
Open published response
15 Jan2015
Exeter and Greater Devon
Concerns raised2
1. Failure to limit medication supplies for patients with a history of prescribed-medication overdose
2. Lack of a computer-system warning for patients with a history of overdose
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.
Respondent positions 5
1. Position
  The practice does not agree that too many zopiclone pills were prescribed, as no single prescription exceeded one month’s supply.
  Stated by Axminster Medical PracticeDisputes the concern
1. Position
  Existing computer prescribing prompts and pharmacist or dispenser alerts are considered sufficient safeguards for zopiclone prescribing.
  Stated by Axminster Medical PracticeExisting arrangements considered sufficient
2. Position
  Restricting prescriptions cannot prevent patients from stockpiling regular medication or accessing other toxic medicines, including over-the-counter drugs.
  Stated by Axminster Medical PracticeUnable to act
3. Position
  A special flag for previous overdoses is considered problematic because it may be irrelevant, misleading, judgemental or offensive.
  Stated by Axminster Medical PracticeDisputes the concern
4. Position
  Routine review of the accessible medical-record summary is considered sufficient to identify relevant previous overdoses during patient assessment.
  Stated by Axminster Medical PracticeExisting arrangements considered sufficient
AI-generated summary

Judith Anne SAVILLE · 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

Judith Anne Saville, who had a long history of agitated depression and previous psychiatric admissions and ECT treatment, was found deceased at home on 28 January 2014. The inquest concluded that she died from a Zopiclone and Paracetamol overdose and that she had taken her own life. Concerns included the quantity of medication prescribed, the need for warnings about a history of overdose in the practice’s computer system, and implementation and auditing of an action plan.

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 limit medication supplies for patients with a history of prescribed-medication overdose
Wider context from the report
“(1) For the attention of ████████ In his evidence ████████ told the Court that Mrs Saville’s death had been reviewed at a significant events meeting in his practice. I was told that it was felt he had prescribed too much medication, particularly as the person who had a past medical history that included overdoses of prescribed medication. ████████ said that there was now an increased awareness on the Practitioners not to prescribe so much medication in similar circumstances. He felt that a supply of no more than a week’s worth of medication would be appropriate. ████████ said that the system could be made more robust by introducing a warning on the firm’s computer system. This would assist Practitioners by drawing to their attention a past medical history of overdose. It was felt that this may particularly be of benefit to locum doctors who would not necessarily have the same recall of a patient as a partner in the practice. ”
Source location
Judith Anne SAVILLE · 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
Lack of a computer-system warning for patients with a history of overdose
Wider context from the report
“(1) For the attention of ████████ In his evidence ████████ told the Court that Mrs Saville’s death had been reviewed at a significant events meeting in his practice. I was told that it was felt he had prescribed too much medication, particularly as the person who had a past medical history that included overdoses of prescribed medication. ████████ said that there was now an increased awareness on the Practitioners not to prescribe so much medication in similar circumstances. He felt that a supply of no more than a week’s worth of medication would be appropriate. ████████ said that the system could be made more robust by introducing a warning on the firm’s computer system. This would assist Practitioners by drawing to their attention a past medical history of overdose. It was felt that this may particularly be of benefit to locum doctors who would not necessarily have the same recall of a patient as a partner in the practice. ”
Source location
Judith Anne SAVILLE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The practice does not agree that too many zopiclone pills were prescribed, as no single prescription exceeded one month’s supply.

Verbatim wording from the response
“In the situation in which normally we prescribe Zopiclone, short courses of limited numbers of pills are advisable and our computer system automatically offers us this choice with a label which advises against repeat or regular use. There will inevitably be some patients for whom it has been decided that a regular prescription of one months supply is appropriate. In Mrs Saville’s particular circumstance we would not necessarily agree that ████████ prescribed too many zopiclone pills, although we sympathise with his comments. Viewing her prescribing records it appears that she was not prescribed on any single occasion more than a months supply at the dose ████████ had decided on. We would certainly all agree that in cases where there is a heightened risk of suicide we would endeavour to restrict all supplies of potentially toxic medication of any type.”

Source location
2015-0011-Response-by-Axminster-Medical-Practice
Page 1 · response
Published 15 January 2015
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing computer prescribing prompts and pharmacist or dispenser alerts are considered sufficient safeguards for zopiclone prescribing.

Verbatim wording from the response
“In the situation in which normally we prescribe Zopiclone, short courses of limited numbers of pills are advisable and our computer system automatically offers us this choice with a label which advises against repeat or regular use. There will inevitably be some patients for whom it has been decided that a regular prescription of one months supply is appropriate. In Mrs Saville’s particular circumstance we would not necessarily agree that ████████ prescribed too many zopiclone pills, although we sympathise with his comments. Viewing her prescribing records it appears that she was not prescribed on any single occasion more than a months supply at the dose ████████ had decided on. We would certainly all agree that in cases where there is a heightened risk of suicide we would endeavour to restrict all supplies of potentially toxic medication of any type.”

Source location
2015-0011-Response-by-Axminster-Medical-Practice
Page 1 · response
Published 15 January 2015
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
Restricting prescriptions cannot prevent patients from stockpiling regular medication or accessing other toxic medicines, including over-the-counter drugs.

Verbatim wording from the response
“Our local pharmacists and dispensers do also flag to us when patients appear to be receiving medications earlier than would be expected. As you will understand however, restricting prescribed medications would not prevent patients who have chosen to “stockpile” regular medications from holding large numbers of any pill which we prescribe regularly. There are many medications which are much more toxic than zopiclone and of course many over the counter medications which would also be toxic in overdose.”

Source location
2015-0011-Response-by-Axminster-Medical-Practice
Page 1 · response
Published 15 January 2015
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
A special flag for previous overdoses is considered problematic because it may be irrelevant, misleading, judgemental or offensive.

Verbatim wording from the response
“To have a special flag which highlights that a patient has taken overdoses in the past would be problematic because this is not relevant information for many such people and significant numbers of patient have taken overdoses in the past but are not at increased risk of repeating any form of self-harm. Patients rightly expect that their medical records are both accurate and do not stress information which might in some way be viewed as judgemental and a special flag or message which is given more weight than any other part of their medical history might well be offensive to some.”

Source location
2015-0011-Response-by-Axminster-Medical-Practice
Page 2 · response
Published 15 January 2015
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
Routine review of the accessible medical-record summary is considered sufficient to identify relevant previous overdoses during patient assessment.

Verbatim wording from the response
“Your recommendations have lead us to consider the methods available to GPs in assessing whether a patient might have an increased risk of suicide. Mrs Saville’s medical records record clearly in the summary that she had taken two overdoses, one in 1994 after what is described as a marriage break-up and another in 2010. All the GP’s agreed that it would be a normal part of assessing a patient to look at the summary page which is clear and easily accessible. All the information contained therein would naturally be taken into account especially if it is relevant to the reason a patient is consulting.”

Source location
2015-0011-Response-by-Axminster-Medical-Practice
Page 2 · response
Published 15 January 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised2

Failure to limit medication supplies for patients with a history of prescribed-medication overdose

Lack of a computer-system warning for patients with a history of overdose

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Actions described in response 3

Respondent positions 2

Respondent positions 5