Recurring concern

Incomplete clinical history-taking

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First reported 31 Mar 2014•Latest report 31 Oct 2025

Definition

What this concern includes

Includes failures to obtain a sufficiently complete and relevant patient history during clinical assessment, consultation, admission, clerking or health checks, including failure to elicit relevant information from the patient or appropriate informants.

Not included

  • Excludes failures limited to recording or documenting information that was already obtained, unless the report also identifies incomplete history-taking.
  • Excludes failures limited to communicating or handing over an already established history, unless the underlying history was not adequately obtained.
  • Excludes deficiencies in treatment, referral, escalation or testing where incomplete history-taking is not itself the recurring unsafe condition.
Reports
55

Distinct published reports

Individual concerns
58

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
96

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England11
Department of Health and Social Care6
North East London NHS Foundation Trust4
Barts Health NHS Trust3
Care Quality Commission3
Hampshire and Isle of Wight Healthcare NHS Foundation Trust3
Manchester University NHS Foundation Trust3
General Medical Council2
Greater Manchester Mental Health NHS Foundation Trust2
Medway NHS Foundation Trust2
Ministry of Justice2
North London NHS Foundation Trust2
Royal College of Emergency Medicine2
Royal College of Paediatrics and Child Health2
Surrey and Borders Partnership NHS Foundation Trust2

Concerns and responses across reports

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

  1. Exeter and Greater Devon

    AI-generated summary

    Matthew Llewellyn-Jones · 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

    Matthew Llewellyn-Jones, who had been detained under section 2 of the Mental Health Act after becoming acutely unwell with psychosis, left a locked hospital ward unaccompanied and was later found hanging by a ligature in the hospital grounds. The concerns included breaches of the ward’s locked door, predictable observations, inadequate collection of information from family and carers, insufficient assessment and observation, inadequate staff induction, and staffing levels that contributed to failings in his care and security.

    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 of the admission recording system to make obtaining carer and family information mandatory

    Wider context from the report

    “(3) A new system of note recording has been introduced since this death, but it still does not make obtaining information from carers and/or family mandatory on admission. The importance of this information was readily acknowledged by the Trust in their internal inquiry and at inquest. The electronic recording system should be able to facilitate capturing such information with the use of mandatory fields to avoid this oversight and could assist the Trust in achieving their stated aims in this respect. ”

    Source location

    Matthew Llewellyn-Jones · 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

    Use an active Care Notes care-planning field to record information sought from carers or family.

    Verbatim wording from the response

    “A copy of the Care Notes forms are attached, the specific changes that have been made are-”

    Source location

    2016-0385-Response-by-Devon-Partnership-NHS-Trust
    Page 2 · response
    Published 25 October 2016

    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

    Activate a Care Notes risk-assessment area recording carers’ and family members’ views.

    Verbatim wording from the response

    “• Risk Assessment (Specific area looking at carer/family views) – this is due to become active by the end of January 2017 (ref 2.2)”

    Source location

    2016-0385-Response-by-Devon-Partnership-NHS-Trust
    Page 2 · response
    Published 25 October 2016

    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 mandatory field for carer and family information will not be added; free-text recording and audit follow-up are considered sufficient.

    Verbatim wording from the response

    “The introduction of a mandatory field has been considered by the Care Notes team and senior clinical colleagues. The decision has been made not to add as a mandatory field, it will continue to be recorded as a ‘free text’ field. The rational for this decision is that a mandatory field could be completed with a generic comment for example ‘have been unable to contact family at this time’, when audited as detailed below, this would be identified as completed. If the field is left ‘blank’ the audit will highlight this and allow individual review and follow up with the staff member concerned.”

    Source location

    2016-0385-Response-by-Devon-Partnership-NHS-Trust
    Page 2 · response
    Published 25 October 2016

    Open published response

  2. Manchester City

    AI-generated summary

    Leslie Johnson · 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

    Leslie Johnson, who required supported care and had a swallowing assessment recommending a soft diet and supervision, died in hospital after being left unsupervised while eating an egg mayonnaise sandwich. A post-mortem examination found that he died from acute aspiration of food. Concerns included failures to assess or recognise his lack of mental capacity and failures to communicate his care plan and swallowing requirements between community carers and the hospital.

    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 provide or obtain up-to-date mental health and care-plan information on hospital admission

    Wider context from the report

    “3. Details of his mental health condition and in particular his care plan did not accompany him and/or were not supplied by his carers or his care co-ordinator to the hospital, but nor did the hospital check or request information from those looking after him in the community. The concern is that in this case, the deceased’s death was avoidable and had there been appropriate communication between all those looking after him, steps would have been taken to ensure his oral diet complied with his current SALT assessment pending a review. It is suggested that the Hospital Trust, the Mental Health Trust and any caring organisation (whether that be a charity or a private organisation) should have policies and protocols which are applied to ensure that up to date information is provided upon admission to or discharge from hospital. ”

    Source location

    Leslie Johnson · Prevention of Future Deaths report
    Page 4 · 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

    Implement a Trustwide policy or pathway for proactively gathering complex and vulnerable patients’ up-to-date information from external health providers.

    Verbatim wording from the response

    “Currently as a Trust we do not have a formal policy in place for the sharing of up to date information for patients who are vulnerable or have complex conditions. Whilst staff will informally liaise with care agencies or primary care, this is ad hoc and not an embedded process therefore relies on the staff providing care to a patient to proactively consider the information that may be held elsewhere. There are exceptions to this however, such as patients with learning disabilities, where there is a formal process in place through the use of their LD passport; however this is not consistent across other patient groups. As a result of the findings of this case we will implement a Trustwide initiative regarding the development of a policy or pathway for complex and vulnerable patients which will include proactively gathering information from health providers outside of the Trust.”

    Source location

    MORRISON-Leslie-Response
    Page 2 · response
    Published 28 July 2016

    Open published response

  3. Manchester South

    AI-generated summary

    Peter Arthur Rowe · 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 Arthur Rowe was administered the penicillin-based antibiotic co-amoxiclav despite a GP referral letter recording a penicillin allergy. He developed a worsening rash, was admitted to hospital with toxic epidermal necrolysis, and died on 8 February 2016 following deterioration. Concerns included the deletion of recorded allergy information and reliance on allergy answers despite Mr Rowe’s poor memory and his wife’s lack of knowledge of his allergy.

    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 assess the reliability of negative allergy histories from patients or accompanying persons

    Wider context from the report

    “3. On the evidence heard at the Inquest Mr Rowe suffered from very poor memory following his stroke in 1993. In the premises I am concerned that negative answers to questions regarding any allergies stated to have been put to both Mr Rowe and ████████ were accepted at face value when, a) Mr Rowe suffered from significant memory loss and decreased cognitive function, and b) When ████████ would not necessarily have known of her husband’s allergy (and indeed did not). ”

    Source location

    Peter Arthur Rowe · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester City

    AI-generated summary

    Norma Edwina Holden · 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

    Norma Edwina Holden presented to the Accident and Emergency Department with abdominal pain, facial and mouth swelling, a swollen tongue and muffled speech, and was later found to have died from septic shock. Concerns included incomplete history-taking and communication to treating doctors, failure to recognise and act on apparent symptoms such as possible anaphylactic shock, lack of appropriate tests, and failure to obtain basic blood tests for infection or sepsis.

    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

    Incomplete history taking

    Wider context from the report

    “During the inquest evidence was heard to the fact that Mrs Holden presented to the Accident and Emergency Department with a history of abdominal pain. Triage history stated swelling to face and mouth. It appears that Mrs Holden had a swollen tongue and her speech was muffled. ████████ was unaware of the symptoms of swollen tongue and facial swelling. I am concerned that the history taking is incomplete and not reported to treating doctors appropriately and that obvious symptoms appear to have not been noticed and actioned, such as possible anaphylactic shock, and appropriate tests conducted. In addition, basic blood tests were not obtained for analysis of any infection/sepsis, to enable appropriate targeting of antibiotics. ”

    Source location

    Norma Edwina Holden · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Mid Kent and Medway

    AI-generated summary

    Alwyn Ann Head · 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

    Alwyn Ann Head was admitted to hospital after falls caused a fractured femur at the site of a prosthesis. She underwent surgery, developed an MRSA wound infection, deteriorated after further surgery, and died on 20 August 2015. Concerns included failure to establish her MRSA history, lack of prophylactic Teicoplanin, absence of a post-operative wound care plan, inadequate evidence of wound inspection, and meaningless nursing documentation about the wound.

    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 establish MRSA history before surgery

    Wider context from the report

    “(1) That Mrs Head had a history of MRSA was not established prior to surgery despite opportunities in 3 different hospital departments to obtain this information from Mrs. Head or her family ”

    Source location

    Alwyn Ann Head · 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

    Introduce new admission and transfer documentation to record patient infection status.

    Verbatim wording from the response

    “We acknowledge that although Mrs Head had a history of MRSA this was not established prior to the surgical procedure. We have therefore introduced a series of measures to reduce the risk of this situation re-occurring, which are:”

    Source location

    A-head-Response
    Page 1 · response
    Published 23 March 2016

    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

    Disseminate the new infection-status documentation through twice-monthly infection-control update sessions.

    Verbatim wording from the response

    “• Staff are made aware of the new documentation on the twice monthly level 3 infection control update sessions.”

    Source location

    A-head-Response
    Page 1 · response
    Published 23 March 2016

    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

    Check completion of infection-status documentation during daily patient reviews and provide nursing feedback.

    Verbatim wording from the response

    “• As part of their daily routine patient reviews the infection control team are checking the new documentation has been completed and provide the nursing staff with feedback at the time.”

    Source location

    A-head-Response
    Page 1 · response
    Published 23 March 2016

    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

    Amend the surgical safety checklist to verify MRSA status and history with patients and staff before induction and at theatre sign-in.

    Verbatim wording from the response

    “The surgical safety checklist is being amended to ensure MRSA status and MRSA History is verified by two staff and with the patient pre operatively in the Anaesthetic Room before induction and again with the whole theatre team at ‘sign in’.”

    Source location

    A-head-Response
    Page 2 · response
    Published 23 March 2016

    Open published response

  6. South Yorkshire (Eastern)

    AI-generated summary

    Marc Jason Stephen Poole · 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

    Marc Jason Stephen Poole, aged 6, was admitted to hospital on 16 May 2015 with suspected infection and died in Sheffield Children’s Hospital on 18 May 2015 from the effects of pneumococcal septicaemia. The report identified concerns about delayed antibiotic treatment, poor communication, inaccurate observation and warning-score recording, inadequate paediatric sepsis guidance, dissemination of medical information, and poor record keeping.

    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 obtain and properly consider relevant information from parents

    Wider context from the report

    “(1) Poor communication on a number of levels Insufficient discussion with the parents regarding history, insufficient weight attached to the information they did provide at the time of admission and subsequently. Absence of any protocols of guidance as to how best to communicate with children with disabilities such as autism as MJ had. Communications between staff were poor, HCAs to nurses, nurses to doctors and between junior doctors and senior doctors. Ineffective communication of microbiology results which had been phoned through to the ward but not immediately passed on to those who needed to undertake assessment. ”

    Source location

    Marc Jason Stephen Poole · 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

    Review the Paediatric IPOC and require documentation of communication needs and disability-related communication limitations.

    Verbatim wording from the response

    “With respect to the discussion with the parents regarding a child’s clinical history, in order to ensure better communication the team have reviewed the Paediatric IPOC. Staff have been made aware of the need to listen to parents and take their views into consideration when assessing the clinical picture in any child who is admitted. Should children suffer from disabilities, medical and nursing staff will record, under the respective part of the Paediatric IPOC, how such children are communicated with and whether their disability limits their ability to communicate with strangers and hence the need to have more detailed and in depth conversations with parents. This situation will continue to pertain throughout the child’s stay in hospital.”

    Source location

    Marc-Poole-Response
    Page 2 · response
    Published 2 February 2016

    Open published response

  7. East London

    AI-generated summary

    EMMA LOUISE BRAY · 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

    Emma Louise Bray had a history of problems with mood and was assessed by mental health services in January 2015 after her mood deteriorated. Her family reported worsening symptoms, hopelessness, suicidal research and concerns about her medication, but several planned referrals, follow-up actions and communication of information did not occur. She hanged herself on 25 February 2015. Concerns included incomplete medication and treatment histories, failures in follow-up and referral, inadequate response to family information, failures to record emails, unclear medication-risk communication, and wider deficiencies in service guidance and monitoring.

    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 obtain a proper treatment and medication history from the patient and primary sources

    Wider context from the report

    “During the evidence I was told that a number of things had not happened that ought to have done: (a) A proper medication history was not taken on assessment (b) EB’s treatment and medication history were not obtained from either public or private sector providers. (c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days. (d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition. (e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team. (f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring. (g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment. (h) There should have been regular contact with EB thereafter, initiated by IT. (i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care. (j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment. (k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns. (l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay. On a systemic level, the following issues are of concern: (a) Absence of guidelines about what information must be obtained on assessment, including the medication history. (b) Absence of guidance about where that information should be obtained from: the patient / primary sources. (c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services. (d) Lack of clarity about who should be the person between patients and the IT. (e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them. (f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be. (g) An absence of guidelines giving staff timescales within which referrals should take place. (h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place. (i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history. (j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person. (k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of. (l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes. (m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff. ”

    Source location

    EMMA LOUISE BRAY · 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

    Improve the quality of assessment and treatment plans.

    Verbatim wording from the response

    “The plan has five broad objectives within which your specific concerns have been addressed. These are:”

    Source location

    2015-0438-Response-by-NELFT-NHS-Trust
    Page 1 · response
    Published 16 November 2015

    Open published response

  8. Berkshire

    AI-generated summary

    Miss Chandni Nigam · 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

    Miss Chandni Nigam, a 19-year-old woman with a history of depression and suicidal ideation, died after being struck by a train at Twyford Railway Station on 4 February 2014. The report raised concern that the NHS Mental Health Team did not obtain relevant history or input from her previous private clinicians when care transferred to the NHS.

    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 obtain relevant history and treatment input from private clinicians

    Wider context from the report

    “(1) During the course of her on-going care, Miss Nigam was being seen by private psychiatrist and psychologist. When she reverted to NHS Mental Health Team Care she still had on-going sessions with the private psychologist. There was an opportunity to gain history and input from the private clinicians as to Miss Nigam’s history, previous treatment and what had been successful and less successful. No attempt to obtain that history or any input from the previous private clinicians appears to have been made. There was an opportunity to obtain helpful and effective historical information that may have assisted in the treatment of Miss Nigam by the Mental Health Team. ”

    Source location

    Miss Chandni Nigam · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Inner North London

    AI-generated summary

    Finnulla Catherine MARTIN · 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

    Finnulla Catherine Martin took her own life by jumping from the sixth-floor balcony of her home less than an hour after discharge from Whittington Hospital following a mental health assessment. Concerns included failures to obtain and share relevant information, incomplete assessment of suicide and harm risks, inadequate collateral history-taking, uncertainty about procedures for police-accompanied voluntary attendance, and failure to characterise the police contact as an emergency after Ms Martin left hospital.

    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 establish the circumstances leading to police involvement and the identity of the caller

    Wider context from the report

    “5. He did not address his mind to what had led up to the police being called for Ms Martin, nor who had called them. ”

    Source location

    Finnulla Catherine MARTIN · 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 obtain collateral history from family members before concluding the interview

    Wider context from the report

    “6. Neither doctor nor nurse obtained a collateral history of events from a family member before concluding their interview with Ms Martin. ”

    Source location

    Finnulla Catherine MARTIN · Prevention of Future Deaths report
    Page 3 · 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

    Develop and finalise Emergency Department guidelines for patients brought by police.

    Verbatim wording from the response

    “a) Development of care guidelines relating to patients brought into the Emergency Department by the police.”

    Source location

    2015-0173-Whittington-Health-NHS-Trust
    Page 2 · response
    Published 29 April 2015

    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

    Pilot the mental health assessment proforma and make it available to mental health colleagues.

    Verbatim wording from the response

    “b) To implement use of a mental health Proforma to improve the quality of assessments and ensure this is available to mental health colleagues”

    Source location

    2015-0173-Whittington-Health-NHS-Trust
    Page 2 · response
    Published 29 April 2015

    Open published response

  10. Inner South London

    AI-generated summary

    Laurence Boyens · 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

    Laurence Boyens died in prison on 15 November 2012 from Methadone, Tramadol and Diazepam intoxication. The jury identified concerns about the combination and interaction of prescribed drugs, failures to monitor intoxication symptoms and blood pressure, and failures to suspend or withhold Methadone and Tramadol when signs of toxicity were present.

    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

    Prescribing multiple medicines without a sufficiently complete clinical assessment and medication history

    Wider context from the report

    “4. ████████ ████████ was represented at the inquest and the following evidence gave rise to concerns: • He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison. • When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam. • He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing. • He said that he did not know whether he should stop Methadone if the BP was low. • Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy. • At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered. • At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered. • He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives. ”

    Source location

    Laurence Boyens · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026