1 Oct 2025 Milos JANKOVIC · Prevention of Future Deaths report South Wales Central
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Concerns raised 2
Lack of prescribing prompts to assess Barrett’s-related red flags for endoscopy View source Lack of prescribing prompts to identify previously diagnosed Barrett’s patients requiring surveillance 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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Milos JANKOVIC · Prevention of Future Deaths report
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Report summary
Milos JANKOVIC had been diagnosed with Barrett’s Oesophagus in 2014 but was lost to follow-up surveillance after bowel cancer took priority. In 2020, he developed symptoms and was found to have brain metastases from primary oesophageal cancer. Concerns included inadequate processes for Barrett’s surveillance, particularly in primary care, and the absence of recall or prescribing prompts to identify patients needing surveillance or endoscopy.
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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 prescribing prompts to assess Barrett’s-related red flags for endoscopy
Wider context from the report “(4) When prescribing drugs such as omeprazole or other PPIs for symptoms which may relate to Barrett’s, there is no prompt for GPs to consider whether the patient hits the relevant red flags which may benefit from endoscopy rather than a course of medication , or whether they have previously been diagnosed with the condition and ought to be under surveillance.
” Source location Milos JANKOVIC · Prevention of Future Deaths report
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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 prescribing prompts to identify previously diagnosed Barrett’s patients requiring surveillance
Wider context from the report “(4) When prescribing drugs such as omeprazole or other PPIs for symptoms which may relate to Barrett’s, there is no prompt for GPs to consider whether the patient hits the relevant red flags which may benefit from endoscopy rather than a course of medication, or whether they have previously been diagnosed with the condition and ought to be under surveillance .
” Source location Milos JANKOVIC · Prevention of Future Deaths report
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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 Secondary care should continue managing Barrett’s Oesophagus surveillance recalls; GP recalls or prompts would duplicate responsibilities and cause confusion.
Verbatim wording from the response “In terms of recalling people with Barrett’s Oesophagus for surveillance procedures, it is the secondary care team which manages this process. The need for surveillance is added to a patient’s record by the patient administration system used by the health board. Health boards operate standardised recall procedures and follow-up procedures for non-responders to invite people for their surveillance appointments.” Source location Response from Health and Social Services of Wales
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20 Jun 2025 Mr Patrick Viles · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Prescribing medication despite significant mental health concerns View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Mr Patrick Viles · Prevention of Future Deaths report
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Report summary
Mr Patrick Viles died after taking an intentional overdose of medication at home, in the context of suicidal ideation and previous overdosing. The report raises concern that medication was prescribed after a psychologist had identified significant concerns about his mental health and the need for urgent psychiatric input. It could not be determined at the inquest where the medication used in the overdose had been obtained.
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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 Prescribing medication despite significant mental health concerns
Wider context from the report “You did note that you had referred Mr Viles to a psychologist, who consulted with him on 19/6/24 and raised concerns regarding the need for urgent psychiatric input, given his suicidal ideation . You also noted that you reviewed him after the psychologist’s input and concluded that he was not suitable for spinal cord stimulation.
At the inquest it could not be determined from where Mr Viles had obtained the medication on which he overdosed. I therefore wrote a letter of concern to you, asking if you had prescribed medication (as had been suggested by the mental health trust’s evidence).
You replied on 13/6/25, setting out that you had prescribed four weeks’ worth of ████████ on 28/6/24 (nine days after the psychologist’s consultation) .
I am concerned that you prescribed this medication after the psychologist you had referred Mr Viles to had raised significant concerns regarding his mental health .
” Source location Mr Patrick Viles · Prevention of Future Deaths report
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Concerns raised 1
Lack of information being made available to the GP to prevent duplicitous prescribing View source
Linked responses
NHS Surrey and Sussex Integrated Care Board Sussex Partnership NHS Foundation 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. 4
NHS Surrey and Sussex Integrated Care Board
Roll out the shared care record to primary care during the 2025/2026 financial year.
View source
Sussex Partnership NHS Foundation Trust
Migrate to the SystmOne electronic patient record system.
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Sussex Partnership NHS Foundation Trust
Enable two-way, real-time information sharing with GP practices and provide sharing agreements.
View source
Sussex Partnership NHS Foundation Trust
Establish electronic prescribing, prioritising community electronic prescribing within the programme.
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Margaret Kagure Pauline REECE · Prevention of Future Deaths report
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Report summary
Margaret Kagure Pauline Reece died on 7 March 2023 after being found hanging at her home address. The principal concern was that inadequate information-sharing between mental health services and the GP could result in patients receiving no medication or excessive medication due to duplicitous prescribing.
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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 information being made available to the GP to prevent duplicitous prescribing
Wider context from the report “The MATTERS OF CONCERN are that in the absence of information being made available to the GP there is a risk that patients will not receive any medication or receive excessive amounts of medication due to the risk of duplicitous prescribing .
” Source location Margaret Kagure Pauline REECE · 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 Roll out the shared care record to primary care during the 2025/2026 financial year.
Verbatim wording from the response “NHS Sussex is in the process of rolling out the shared care record to primary care in this financial year (2025/2026). In the coming years the information NHS providers will be able to access about a patient will be replaced by the national Shared Care Record which NHS England is currently developing.” Source location Response from NHS Sussex
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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 Migrate to the SystmOne electronic patient record system.
Verbatim wording from the response “I am able to confirm that after a lengthy consultation, procurement and enablement process, in November 2025 the Trust will be migrating to a new Electronic Patient Record system, namely SystmOne. This system is widely used by many other NHS providers, including GPs and has the potential for incorporated prescribing functions. After November, the Trust will therefore be able to integrate with GP surgery systems and facilitate two-way and real time sharing of information which should alleviate this risk considerably.” Source location Response from Sussex Partnership NHS
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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 Enable two-way, real-time information sharing with GP practices and provide sharing agreements.
Verbatim wording from the response “I am able to confirm that after a lengthy consultation, procurement and enablement process, in November 2025 the Trust will be migrating to a new Electronic Patient Record system, namely SystmOne. This system is widely used by many other NHS providers, including GPs and has the potential for incorporated prescribing functions. After November, the Trust will therefore be able to integrate with GP surgery systems and facilitate two-way and real time sharing of information which should alleviate this risk considerably.” Source location Response from Sussex Partnership NHS
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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 Establish electronic prescribing, prioritising community electronic prescribing within the programme.
Verbatim wording from the response “In addition, as a part of our broader IT developments we are also working to establish electronic prescribing which will further enhance the safety of prescribing practices. This is a more complex part of the programme and the time frame for a complete roll out is not clear at this stage, however it remains a priority for us. Given the risk concerns you have identified,” Source location Response from Sussex Partnership NHS
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4 Apr 2025 Jacqueline GREEN · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1
Failure to ensure accurate patient weights are entered before paracetamol prescribing View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Jacqueline GREEN · 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
Jacqueline GREEN was admitted to Bedford Hospital after a fall and was found to be very weak, frail, cachectic and dehydrated. She received paracetamol at a dose intended for patients weighing over 50 kg despite weighing 33.6 kg, subsequently developed paracetamol-induced liver injury and died from liver failure. The concerns included inadequate safeguards for prescribing paracetamol to low-weight adults, unexplained variation in the administration of doses, and incomplete implementation of relevant safety measures.
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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 ensure accurate patient weights are entered before paracetamol prescribing
Wider context from the report “3. Despite the PSII report referencing the 2022 HSSIB report and recommending that this should be shared with staff, relevant Safety Observations made in the HSSIB Report appear to have been insufficiently addressed:
(a) Although Bedford Hospitals NHS Trust are now using the Nevercentre electronic record system which, since 28th February 2024, has included the height and weight of patients and prevents a prescribing doctor from prescribing without a patient’s weight having first been entered, staff are still able to enter a estimated weight and there do not appear to be any alerts on this system to advise of the need for weight accuracy in the prescription of oral paracetamol and consideration of the risk of liver toxicity in those weighing under 50 kg (as advised in Safety Observation 02/2022/151);
(b) Whilst the PSII report states as an Action that “Patients should be weighed on admission and the information documented”, other than the provision of a ‘pat slide’, no other practical actions are planned for actually achieving this outcome, particularly in respect of those adults at risk of an unintentional paracetamol overdose, such as an alert aimed at those administering medication as well as those prescribing it (as advised in Safety Observation 02/2022/151).
” Source location Jacqueline GREEN · 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 Add EPMA prescribing prompts requiring accurate weight recording and appropriate paracetamol dosing, including liver-toxicity warnings below 50 kilograms.
Verbatim wording from the response “There is now a prompt when prescribing paracetamol (all routes) on EPMA that reminds prescribers of the need to ensure there is an accurate weight recorded and that the dose is appropriate.” Source location Response from Bedford Hospitals NHS Foundation Trust
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Concerns raised 1
Failure to prescribe oral antibiotics at discharge despite microbiology advice 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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Andrew James Tizard-Varcoe · 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 James Tizard-Varcoe died at home on 11 May 2022 due to the progression of an ear infection, later described at inquest as complications of necrotising otitis externa. Concerns included fragmented care across three hospital trusts, difficulties accessing medical records and establishing responsibility, delayed outpatient follow-up, and discharge without oral antibiotics despite microbiology advice.
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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 prescribe oral antibiotics at discharge despite microbiology advice
Wider context from the report “(3) In addition, on 1 November 2021, Mr Tizard-Varcoe was discharged from the Royal and Devon Hospital without a prescription for oral antibiotics despite advice from microbiologists to do so ; the evidence showed that this was a clinical decision made by a junior ear nose and throat doctor against an improving clinical picture . The discharge was overseen by a consultant from a different specialism due to Mr Tizard-Varcoe’s health needs at the time.
Evidence at the inquest from the responsible ear nose and throat consultant, indicated that he would probably have prescribed antibiotics on advice of microbiologists. Due to the progression of the infection from the ear canal into the bone at the base of the skull there is a real possibility that the clinical presentation did not reflect the true situation and this was a missed opportunity to provide continuity of treatment.
” Source location Andrew James Tizard-Varcoe · 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 Appoint two permanent ENT consultants and provide daily named-consultant ward rounds with senior review of discharges and ongoing treatment plans.
Verbatim wording from the response “At the time of Mr Tizard-Varcoe’s discharge, there was a shortage of ENT Consultants which meant that not every discharge could be reviewed by a named Consultant. Since 2022, a further two permanent ENT Consultants have been appointed. This has allowed the team to have a named consultant ward round on a daily basis and this means there is now senior supervision of decision making on every ward round. This includes reviewing all patients due to be discharged as well as their management plan on discharge. With this now in place, I am assured that there would be senior oversight of ongoing treatment and patients such as Mr Tizard-Varcoe would be discharged with appropriate treatment plans in place.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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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 Named consultant ward rounds and discharge-plan reviews are considered sufficient to provide senior oversight of ongoing treatment at discharge.
Verbatim wording from the response “At the time of Mr Tizard-Varcoe’s discharge, there was a shortage of ENT Consultants which meant that not every discharge could be reviewed by a named Consultant. Since 2022, a further two permanent ENT Consultants have been appointed. This has allowed the team to have a named consultant ward round on a daily basis and this means there is now senior supervision of decision making on every ward round. This includes reviewing all patients due to be discharged as well as their management plan on discharge. With this now in place, I am assured that there would be senior oversight of ongoing treatment and patients such as Mr Tizard-Varcoe would be discharged with appropriate treatment plans in place.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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Concerns raised 1
Lack of prescriber understanding of the interaction between ivabradine, amitriptyline and paroxetine View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
National Institute for Health and Care Excellence Royal College of Physicians
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Chloe Elizabeth Burgess · 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
Chloe Elizabeth Burgess was found deceased at home on 8 September 2023. The report states that interactions between amitriptyline, paroxetine and ivabradine, together with an episode of sleep apnoea, contributed to severe cardiac arrhythmia and sudden cardiac death. The principal concerns were that the potential dangers of this medication combination were not widely appreciated and did not trigger alerts in prescribing software, and that prescribers of ivabradine should have a full understanding of the potential interaction.
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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 prescriber understanding of the interaction between ivabradine, amitriptyline and paroxetine
Wider context from the report “The inquest heard evidence that the potential dangers of the combination of amitriptyline, paroxetine and ivabradine is not widely appreciated and does not trigger an alert on the prescribing software used in primary care or by pharmacists. The potential dangers related to a failure to metabolise amitriptyline which can, incrementally, lead to toxicity.
I am also concerned that those prescribing ivabradine should have a full understanding of the potential interaction with amitriptyline and paroxetine .
” Source location Chloe Elizabeth Burgess · Prevention of Future Deaths report
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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 Prescribers are responsible for understanding medicine interactions and applying appropriate caution or monitoring rather than relying solely on software alerts.
Verbatim wording from the response “It is the role of all prescribers to understand the overarching mechanisms of action of medicines they may prescribe, and where similar actions occur by more than one medicine, or might exacerbate pathology in individual patients, particular caution or monitoring should be instituted. It is important that they do not rely on prescribing software, but use recognised reference materials.” Source location Response from Royal College of Physicians
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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 BNF publishers, rather than NICE, are best placed to address concerns about drug interactions.
Verbatim wording from the response “We have reflected on the circumstances surrounding Chloe’s death, and the concerns raised in your report regarding drug interactions. The British National Formulary (BNF) provides key information on the selection, prescribing, dispensing and administration of medicines and we believe that they would be best placed to address your concerns.” Source location Response from National Institute for Health and Care Excellence
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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 NICE cannot comment on drug-interaction concerns because BNF content responsibility remains with its publishers.
Verbatim wording from the response “The BNF is a joint publication of the BMJ Group and Pharmaceutical Press, the publishing division of the Royal Pharmaceutical Society. While we make the BNF available on the NICE website, responsibility for the content remains with the publishers and therefore NICE cannot comment on the concerns you have raised.” Source location Response from National Institute for Health and Care Excellence
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31 Jan 2025 Kim Jeannette ROBINSON · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Failure to assess suicidal behaviour or thoughts in online consultations View source
This report raised 5 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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Kim Jeannette ROBINSON · 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
Kim Robinson died at home in Suffolk on 12 May 2024 after toxicological analysis identified a significantly toxic level of a medication obtained from an online pharmacy. The report identified concerns that the online prescriber could not access her GP records, the ordering process used incorrect details, and the medication was delivered in a quantity that gave her direct access to a fatal amount. The report stated that the online prescription system needed review.
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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 assess suicidal behaviour or thoughts in online consultations
Wider context from the report “1. Following Kim’s tragic death the GP who had prescribed the prescription of ████████ to Kim, reviewed the current online system in place and identified five areas where in his evidence he identified changes could be made.
The GP stated there was:-
a) The need for online prescribers to be able to access a patient’s records (at least the Summary Care Records). These records could be attached to the consultation for review by the prescriber.
b) All patients could be asked for consent to share the details of their prescriptions with their current GP and/or regular practitioner. When consent is given, it was suggested a notice should be sent to these healthcare providers at the same time the medicine is delivered to the patient. Without such consent, the patient’s order should not be accepted.
c) Prescribers could have the ability to add comments when reviewing a consultation, whether it is approved or vetoed.
d) All consultations could include the question: “Have you ever had suicidal behaviour or thoughts?”
e) Prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies.
Had these features been present on the on-line system, the GP stated he would not have issued a prescription of ████████ to Kim.
In light of the evidence heard in this case I believe the current system of on-line prescription service needs to be reviewed.
2. It is of note, that the matter of concern regarding the ease in obtaining online prescriptions was previously raised by this court on 15th November 2019 in a Prevention of Future Death report following the tragic death of Deborah Headspeath on 3rd August 2017.
” Source location Kim Jeannette ROBINSON · Prevention of Future Deaths report
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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 If an appropriate organisation requires a standardised suicidal-behaviour question, the GPhC would monitor its inclusion through inspections.
Verbatim wording from the response “In your report you suggest that all consultations could include the question: “Have you ever had suicidal behaviour or thoughts?” On this point, the GPhC expects pharmacies to carry out a risk assessment for every part of the service they provide. If an appropriate organisation stated that this question should be included, then the GPhC would monitor this through its inspection processes.” Source location Response from DHSC
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26 Nov 2024 Amy Jade BUTCHER · Prevention of Future Deaths report Suffolk
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Concerns raised 2
Lack of clinical knowledge about microdosing hallucinogenic mushrooms and its relevance to Lorazepam prescribing View source Failure to make an appropriate medication-concordance assessment when patients use alternative medication because PRN medication is ineffective 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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Amy Jade BUTCHER · 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
Amy Jade Butcher was declared deceased on 14 May 2023 after suspending herself with a ligature around her neck during a heightened anxiety crisis. The inquest identified concerns about a confusing, fragmented system for prescribing mental health medication, and about the decision not to prescribe Lorazepam despite its previous effectiveness for Amy.
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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 clinical knowledge about microdosing hallucinogenic mushrooms and its relevance to Lorazepam prescribing
Wider context from the report “Evidence was heard that a decision had been made by the Mental Health Multi-Disciplinary Team that Lorazepam was not to be prescribed to Amy in any event. The court heard that Lorazepam was highly addictive and the subject of frequent misuse by individuals to whom it was prescribed.
There were two reasons given for the MDT decision.
Firstly, Amy had volunteered to the Mental Health Team, that she had previously purchased online a ‘micro dose of hallucinogenic mushrooms’ to try and alleviate her systems. The court heard that like ‘homeopathic medication’ only a tiny amount of the active hallucinogen found in mushrooms would have been present, but that it was still illegal to possess this in the UK. Amy had told the team that she had only used this once.
The MDT decision was that because this was an illegal drug, because the MDT were unaware that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and because they did not know how it would react with the Lorazepam, no Lorazepam was to be prescribed to Amy.
Secondly, Amy had previously disposed of medications prescribed to her which made her feel worse (a known side effect of some medications in the first few days of taking them). When advised to restart them, repeat prescriptions had to be made.
In addition, just prior to her death Amy volunteered that she had been taking a sleeping tablet (Zopiclone) in the mornings, as well as taking them when she was supposed to at night. Amy had said that her current PRN medication had no effect, but the Zopiclone did help.
As a result, it was recorded by the MDT that Amy was ‘non-concordant’ with her medication regime, therefore making her a higher risk of prescription misuse.
However, in her evidence, the Emergency Department Consultant said she was fully aware of the fact that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and that due to the tiny amount of active hallucinogen it was generally not a barrier to the prescription of any other medication. In addition, the Emergency Department Consultant stated that if an individual had ingested a toxic quantity of hallucinogenic mushrooms, there was no contra-indication for the prescription of Lorazepam as it was often prescribed to reduce the hallucinogenic effects.
In the evidence heard from members of the MDT, it was clear that the illegal use of a ‘micro dose of hallucinogenic mushrooms’ coupled with Amy’s non-concordance, led to the decision not to prescribe her Lorazepam.
As such, a lack of knowledge in relation to the common usage of micro dose hallucinogenic mushrooms as a self-treatment by mental health patients , a lack of knowledge in relation to there being no contra-indications for prescription of Lorazepam if micro dose hallucinogenic mushrooms were being used , and defining Amy as ‘non-concordant’ due to her use of Zopiclone when her PRN medication proved ineffective, prevented a realistic opportunity for the MDT to consider if Lorazepam should have been prescribed to Amy.
” Source location Amy Jade BUTCHER · Prevention of Future Deaths report
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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 make an appropriate medication-concordance assessment when patients use alternative medication because PRN medication is ineffective
Wider context from the report “Evidence was heard that a decision had been made by the Mental Health Multi-Disciplinary Team that Lorazepam was not to be prescribed to Amy in any event. The court heard that Lorazepam was highly addictive and the subject of frequent misuse by individuals to whom it was prescribed.
There were two reasons given for the MDT decision.
Firstly, Amy had volunteered to the Mental Health Team, that she had previously purchased online a ‘micro dose of hallucinogenic mushrooms’ to try and alleviate her systems. The court heard that like ‘homeopathic medication’ only a tiny amount of the active hallucinogen found in mushrooms would have been present, but that it was still illegal to possess this in the UK. Amy had told the team that she had only used this once.
The MDT decision was that because this was an illegal drug, because the MDT were unaware that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and because they did not know how it would react with the Lorazepam, no Lorazepam was to be prescribed to Amy.
Secondly, Amy had previously disposed of medications prescribed to her which made her feel worse (a known side effect of some medications in the first few days of taking them). When advised to restart them, repeat prescriptions had to be made.
In addition, just prior to her death Amy volunteered that she had been taking a sleeping tablet (Zopiclone) in the mornings, as well as taking them when she was supposed to at night. Amy had said that her current PRN medication had no effect, but the Zopiclone did help.
As a result, it was recorded by the MDT that Amy was ‘non-concordant’ with her medication regime, therefore making her a higher risk of prescription misuse.
However, in her evidence, the Emergency Department Consultant said she was fully aware of the fact that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and that due to the tiny amount of active hallucinogen it was generally not a barrier to the prescription of any other medication. In addition, the Emergency Department Consultant stated that if an individual had ingested a toxic quantity of hallucinogenic mushrooms, there was no contra-indication for the prescription of Lorazepam as it was often prescribed to reduce the hallucinogenic effects.
In the evidence heard from members of the MDT, it was clear that the illegal use of a ‘micro dose of hallucinogenic mushrooms’ coupled with Amy’s non-concordance, led to the decision not to prescribe her Lorazepam.
As such, a lack of knowledge in relation to the common usage of micro dose hallucinogenic mushrooms as a self-treatment by mental health patients, a lack of knowledge in relation to there being no contra-indications for prescription of Lorazepam if micro dose hallucinogenic mushrooms were being used, and defining Amy as ‘non-concordant’ due to her use of Zopiclone when her PRN medication proved ineffective , prevented a realistic opportunity for the MDT to consider if Lorazepam should have been prescribed to Amy.
” Source location Amy Jade BUTCHER · 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 Continue monitoring developments concerning benzodiazepine prescribing and emerging evidence for implementation in accordance with future NICE or regulatory guidance.
Verbatim wording from the response “Our clinicians will adhere to their professional codes, national and regulatory guidance in conjunction with the Trust’s Management of Medication Policy.” Source location Response from Norfolk and Suffolk NHS
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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 Extremely limited evidence and absent specific guidance constrain development of advice on Lorazepam use alongside microdosed hallucinogenic mushrooms.
Verbatim wording from the response “Our Chief Pharmacist office has advised that the British National Formulary does not, as a standard, list illegal substances as contra-indications.” Source location Response from Norfolk and Suffolk NHS
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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 Existing NICE guidance is considered to address concerns about which medicines should and should not be prescribed in different circumstances.
Verbatim wording from the response “NICE have reviewed their guideline CG113 on the management of generalised anxiety disorder (GAD) and panic disorder in adults, against your report. They have concluded that the guideline addresses the concerns raised by this very sad case as it covers which medicines should, and should not, be prescribed for the treatment of GAF in different circumstances.” Source location Response from DHSC
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25 Nov 2024 Margaret Mary Feeney · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 1
Lack of measures to prevent excess prescribing to patients at risk of overdose during longer bank holiday periods View source
Linked responses
Department of Health and Social Care Macklin Street Surgery NHS Derby and Derbyshire Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
NHS Derby and Derbyshire Integrated Care Board
Review the GP practice investigation, lessons learned and identified actions, and determine required support with primary care quality and patient safety teams.
View source
NHS Derby and Derbyshire Integrated Care Board
Review the community pharmacy investigation, lessons learned and identified actions, and determine required support with controlled drugs and commissioning teams.
View source
NHS Derby and Derbyshire Integrated Care Board
Disseminate collated learning and prescribing-safety updates through pharmacy newsletters, GP messages, medicines-safety communications and prescribing-leads forums.
View source
NHS Derby and Derbyshire Integrated Care Board
Share learning and concerns with clinical-system providers, requesting consideration and implementation of solutions to prevent recurrence.
View source
Macklin Street Surgery
Conduct a significant event analysis to identify safer arrangements for short-term prescriptions around bank holidays.
View source
Macklin Street Surgery
Move all short-term prescription issue days to Tuesday, notify patients and pharmacies, and place alerts in patient notes.
View source
Macklin Street Surgery
Implement rolling alerts notifying clinicians when patients move onto short-term prescriptions.
View source
Macklin Street Surgery
Review short-term-prescription patients clinically and classify their risk of medication harm, with reassessment at annual medication reviews.
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Macklin Street Surgery
Split high-risk patients’ prescriptions into shorter supplies when specified bank holidays fall on Tuesday.
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Macklin Street Surgery
Seek advice from the Integrated Care Board on using central clinical pharmacy and medicines-management expertise for high-risk patients.
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AI-generated summary
Margaret Mary Feeney · 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
Margaret Mary Feeney was found deceased at home after taking excess prescribed medication, with pneumonia also contributing to her death. The principal concern was that prescribing and pharmacy arrangements around longer bank holiday periods allowed excess medication to be supplied to a patient recognised as being at risk of overdose.
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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 measures to prevent excess prescribing to patients at risk of overdose during longer bank holiday periods
Wider context from the report “I am concerned that measures are not in place at Macklin Street Surgery and Daynight pharmacy to prevent prescription of excess medication to patient’s recognised to be at risk of overdose, either intentional or unintentional , who are ordinarily issued shorter period repeat prescriptions to reduce those risks. This situation arises when early prescriptions are issued due to statutory holiday periods when most pharmacies are likely to be closed. I have been informed that measures have been introduced to prevent excess prescribing by taking account of single day bank holidays, but there are no measures relating to longer bank holiday periods (e.g. Easter) . With electronic patient record and data systems it seems a reasonable presumption that suitable solutions can be identified.
” Source location Margaret Mary Feeney · 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 Review the GP practice investigation, lessons learned and identified actions, and determine required support with primary care quality and patient safety teams.
Verbatim wording from the response “Action number | Overview of DDICB actions | Proposed completion date
INVESTIGATION AND SUPPORT
1a | Review investigation and lessons learnt/ actions identified by the practice. With support of the ICB primary care quality team and ICB patient safety team, identify support required | 7/2/25
1b | Review investigation and lessons learnt/ actions at community pharmacy. With support of Midlands controlled drugs area team and primary care commissioning team, identify support required. | 7/2/25
REVIEW AND COMMUNICATIONS
2a | Extract shared learning from the practice and community pharmacy reports and add lessons to be shared additionally to those raised above, into an incident report, ready to be shared with system colleagues. Learning report ratified | 14/2/25” Source location Response from Derby and Derbyshire Integrated Care Board
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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 community pharmacy investigation, lessons learned and identified actions, and determine required support with controlled drugs and commissioning teams.
Verbatim wording from the response “Action number | Overview of DDICB actions | Proposed completion date
INVESTIGATION AND SUPPORT
1a | Review investigation and lessons learnt/ actions identified by the practice. With support of the ICB primary care quality team and ICB patient safety team, identify support required | 7/2/25
1b | Review investigation and lessons learnt/ actions at community pharmacy. With support of Midlands controlled drugs area team and primary care commissioning team, identify support required. | 7/2/25
REVIEW AND COMMUNICATIONS
2a | Extract shared learning from the practice and community pharmacy reports and add lessons to be shared additionally to those raised above, into an incident report, ready to be shared with system colleagues. Learning report ratified | 14/2/25” Source location Response from Derby and Derbyshire Integrated Care Board
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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 Disseminate collated learning and prescribing-safety updates through pharmacy newsletters, GP messages, medicines-safety communications and prescribing-leads forums.
Verbatim wording from the response “We recommend promoting the use of this feature across all practices as part of a broader effort to strengthen the scheduled prescription process. Sharing this learning with system users can help make prescription management more robust and prevent potential medication-related risks.” Source location Response from Derby and Derbyshire Integrated Care Board
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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 learning and concerns with clinical-system providers, requesting consideration and implementation of solutions to prevent recurrence.
Verbatim wording from the response “We acknowledge that updates to provider clinical systems could play a crucial role in addressing the issues identified. However, given the operational and developmental oversight of these systems lies with their respective clinical system providers, we believe they are best positioned to evaluate and enact the necessary changes.” Source location Response from Derby and Derbyshire Integrated Care Board
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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 Conduct a significant event analysis to identify safer arrangements for short-term prescriptions around bank holidays.
Verbatim wording from the response “In light of Mrs Feeney’s death, the practice conducted a significant event analysis on 8 August 2024 and a copy of that report has been shared with you previously. As part of that review, it was identified that a way of minimising the need to bring forward 7-day prescriptions prior to bank holidays (and therefore reduce the risks associated with patients having additional medication) was to move the day on which 7-day prescriptions were issued. We initially considered changing the issuing day to a Wednesday but we have since decided to move the day of issue to a Tuesday.” Source location Response from Macklin Street Surgery
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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 Move all short-term prescription issue days to Tuesday, notify patients and pharmacies, and place alerts in patient notes.
Verbatim wording from the response “In light of Mrs Feeney’s death, the practice conducted a significant event analysis on 8 August 2024 and a copy of that report has been shared with you previously. As part of that review, it was identified that a way of minimising the need to bring forward 7-day prescriptions prior to bank holidays (and therefore reduce the risks associated with patients having additional medication) was to move the day on which 7-day prescriptions were issued. We initially considered changing the issuing day to a Wednesday but we have since decided to move the day of issue to a Tuesday.” Source location Response from Macklin Street Surgery
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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 Implement rolling alerts notifying clinicians when patients move onto short-term prescriptions.
Verbatim wording from the response “The surgery has now identified all patients who are on short-term prescriptions (which we have defined as having a prescribing period of 14 days or less) and the prescription day for all of these patients has been moved to a Tuesday. Patients and pharmacies have been advised. An alert has also been placed in the patients' notes. We are implementing a rolling alert so that a clinician will be alerted if a patient moves onto short-term prescriptions in the future.” Source location Response from Macklin Street Surgery
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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 short-term-prescription patients clinically and classify their risk of medication harm, with reassessment at annual medication reviews.
Verbatim wording from the response “The surgery is currently in the process of ensuring that the notes of all of the patients who have been identified as being on short-term prescriptions are reviewed by a clinician to assess whether each patient is at high or low risk. However, risk is broader than risk of overuse / overdose. Risk includes risk of medication harm, (that is to say, some drugs would present a greater risk of harm than others if overused or taken in overdose). Therefore, a clinician will determine whether a patient is at high or low risk of harm if the patient takes more than their prescribed dose. This will be reviewed at the annual medication review.” Source location Response from Macklin Street Surgery
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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 Split high-risk patients’ prescriptions into shorter supplies when specified bank holidays fall on Tuesday.
Verbatim wording from the response “Now that all short-term prescriptions have been moved to a Tuesday, the issue of having to alter prescription processes will only arise on the years when Christmas Day, Boxing Day or New Year’s Day fall on a Tuesday. If Christmas Day, Boxing Day or New Year’s Day fall on a Tuesday, the prescriptions for those patients who have been identified by a clinician as being at high risk will be split i.e. the prescription week will be divided so that those patients will receive two shorter prescriptions to cover them for the bank holiday. How the prescription will be split will depend on how the bank holiday falls but could take a 3:4 day format thus minimising the risks as far as possible.” Source location Response from Macklin Street Surgery
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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 Seek advice from the Integrated Care Board on using central clinical pharmacy and medicines-management expertise for high-risk patients.
Verbatim wording from the response “The surgery will write to the Integrated Care Board seeking advice on how we use the ICB system's central clinical pharmacy / medicines management expertise to assist practices with the management of high-risk patients. We will liaise with the Integrated Care Board to determine how our learning from this experience could be shared with other local GP surgeries to assist them in improving their processes around short-term prescribing. We will also highlight to the ICB any potential national level digital constraints.” Source location Response from Macklin Street Surgery
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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 Clinical system providers are responsible for evaluating and implementing necessary updates because they control operational and developmental oversight.
Verbatim wording from the response “We acknowledge that updates to provider clinical systems could play a crucial role in addressing the issues identified. However, given the operational and developmental oversight of these systems lies with their respective clinical system providers, we believe they are best positioned to evaluate and enact the necessary changes.” Source location Response from Derby and Derbyshire Integrated Care Board
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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 Prescribing and dispensing decisions are assigned to responsible clinicians and pharmacists, who must apply clinical judgement and may delay dispensing where concerns arise.
Verbatim wording from the response “You outlined in your report that Ms Feeney had a long history of being prescribed benzodiazepines and codeine and had become dependent on them. It is important to note that the decision to prescribe a particular drug is a clinical one and should be based on the patient’s medical needs. Decisions about what medicines to prescribe are made by the doctor or healthcare professional responsible for that part of the patient’s care and” 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 NHS England, through regional Controlled Drugs Accountable Officers, holds national oversight responsibility for safe controlled-drug management and use.
Verbatim wording from the response “At a national level NHS England has a clear responsibility in providing systems oversight for the management and use of controlled drugs, including benzodiazepines and opioids. NHS England’s Controlled Drugs Accountable Officers (CDAO¹) undertake this role within each geographical region across England. They provide assurance that all healthcare organisations, including pharmacies, adopt a safe practice for appropriate clinical use, prescribing, storage, destruction and monitoring of 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 Risk cannot be mitigated entirely because pharmacies are not routinely open on bank holidays and patients may choose different pharmacies.
Verbatim wording from the response “Unfortunately, it is not possible for the surgery to mitigate risk entirely because of the fact that pharmacies are not routinely open 7 days a week including on all bank holidays and because patients, understandably, have the freedom to choose which pharmacy they would like their prescriptions sent to. As you have identified, this is not an issue that is likely limited to Macklin Street Surgery but is one that is likely to affect all GP surgeries across the country. It should also be appreciated that there are some technical constraints to the digital records system the practice uses (SystmOne) and the reports it is able to generate.” Source location Response from Macklin Street Surgery
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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 Addressing digital reporting constraints requires action by the national system supplier and NHS Digital.
Verbatim wording from the response “Unfortunately, it is not possible for the surgery to mitigate risk entirely because of the fact that pharmacies are not routinely open 7 days a week including on all bank holidays and because patients, understandably, have the freedom to choose which pharmacy they would like their prescriptions sent to. As you have identified, this is not an issue that is likely limited to Macklin Street Surgery but is one that is likely to affect all GP surgeries across the country. It should also be appreciated that there are some technical constraints to the digital records system the practice uses (SystmOne) and the reports it is able to generate.” Source location Response from Macklin Street Surgery
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Concerns raised 1
Failure to access and consider full medical records and risk assessments when prescribing medication changes View source
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AI-generated summary
Margaret Joy Daly · 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
Margaret Joy Daly was an in-patient at Wrexham Maelor Hospital and, despite being assessed as at significant risk of falling, received lorazepam after a doctor prescribed it without reviewing her full records. She later had an unwitnessed fall and sustained the injury that resulted in her death; the principal concern was that sedative prescribing could occur without consideration of the patient’s full medical records and risk assessments.
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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 access and consider full medical records and risk assessments when prescribing medication changes
Wider context from the report “The clinician who prescribed a sedative, did so, without reference to any of Mrs Daly’s notes other than her prescription chart and as a result was unaware of her enhanced falls risk or any other behavioural issues. Whilst I recognise that medication changes may be necessary without the doctor being able to review a patient in person, I am concerned that this may occur without the doctor having access to and considering her full medical records and risk assessments .
” Source location Margaret Joy Daly · 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 Establish a prescribing safety process requiring access to patient notes, communication of falls risk, and escalation or assessment when safe prescribing is uncertain.
Verbatim wording from the response “Having considered the learning, a new process is being established by the East Medical Director to improve safety whilst recognising medication changes may be necessary without the doctor being able to review a patient in person.” Source location Response from BCUHB
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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 Progress development of integrated electronic health records through business cases, Welsh Government-supported mental health work, and collaboration with early implementers and other Welsh organisations.
Verbatim wording from the response “The longer term, and more sustainable solution is the development of an integrated electronic health record and I know our Chief Executive has discussed these developments with you.” Source location Response from BCUHB
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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 Roll out the electronic Prescribing and Medication Administration System across most acute and community specialties, including staff training and access to medication information.
Verbatim wording from the response “The Health Board is also working to roll out an Electronic Prescribing and Medication Administration System (ePMA).” Source location Response from BCUHB
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.