Concerns raised 1
Failure to prescribe guideline-concordant antibiotics for patients previously colonised with ESBL View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Michele Brenda Duckworth · 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
Michele Brenda Duckworth, who had paraplegia, end stage renal failure and a renal transplant requiring immunosuppression, was admitted with profuse diarrhoea and low blood pressure and later deteriorated with sepsis. She died on 23 February 2020, with the post-mortem finding death due to Escherichia coli bacteraemia of unknown source. The principal concern was that Tazocin was prescribed and continued despite previous ESBL colonisation, contrary to the trust guideline.
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 prescribe guideline-concordant antibiotics for patients previously colonised with ESBL
Wider context from the report “(1) The deceased was incorrectly prescribed Tazocin when she was previously colonised with ESBL . It was initially prescribed when she was on the renal ward and was continued when she was transferred to the Intensive Care Department. The antibiotic given in that context was not the antibiotic suggested in the trust guideline , and it was missed after several medical reviews.
” Source location Michele Brenda Duckworth · Prevention of Future Deaths report
Open source report
11 Jan 2021 Natalie Jane Edgington · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2
Failure to consider a lower methadone starting dose for patients with liver disease View source Failure to obtain and verify relevant information about liver disease before prescribing View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Turning Point
Produce and distribute an educational support pack on hepatic dysfunction and methadone metabolism to clinically involved substance-misuse staff.
View source
Turning Point
Develop and roll out a multiple-choice assessment of the educational support pack, with learning monitored through clinical supervision.
View source
Turning Point
Host a clinical session on safe opioid-substitute-treatment prescribing for representatives from every service, supporting subsequent local learning cascades.
View source
Turning Point
Publish a clinical brief reminding all clinical staff about safe opioid-substitute-treatment prescribing.
View source
Turning Point
Carry out a national audit of medical information available to opioid-substitute-treatment prescribers and documented interim considerations or actions.
View source
Turning Point
Provide every organisational team with an NHS.net email address to enable secure information sharing with NHS bodies and employees.
View source See 3 more actions
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AI-generated summary
Natalie Jane Edgington · 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
Natalie Jane Edgington, aged 28, died at her mother’s address on 24 February 2020. She died from the effects of an accumulated dose of methadone, which she was unable to properly eliminate because of impaired liver function. Concerns included prescribing methadone without sufficient information about her liver disease or an up-to-date liver function test, and the absence of evidence that a lower starting dose was considered.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider a lower methadone starting dose for patients with liver disease
Wider context from the report “2. The BNF recommends that consideration should be given to starting patients with a history of liver disease on a lower dose of methadone than the standard starting dose of 30mls. There was no evidence to suggest that any consideration was given to starting the Deceased on a lower dose.
” Source location Natalie Jane Edgington · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to obtain and verify relevant information about liver disease before prescribing
Wider context from the report “1. That prescribers should have full information about the nature and extent of a service user’s liver disease in order to ensure that prescribing is within safe limits. The prescription to the Deceased was issued without relevant medical information that could have been obtained from the GP and/or an up to date liver function test. There is a risk associated with reliance on a service users self-reporting of his/her own medical history particularly against a background of non-attendance at medical appointments.
” Source location Natalie Jane Edgington · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and distribute an educational support pack on hepatic dysfunction and methadone metabolism to clinically involved substance-misuse staff.
Verbatim wording from the response “1) We have produced an educational support pack on “The effects of hepatic dysfunction on the metabolism of methadone”. I attach a copy of this document for your information. This was distributed on 26 January 2021 to all staff within the organisation who have a clinical role in relation to the treatment of substance misuse. Whilst the document as a whole is relevant to the concerns raised, I highlight particularly the recommendations for staff at page 6 of the document which include the following:” Source location Response from Turning Point
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and roll out a multiple-choice assessment of the educational support pack, with learning monitored through clinical supervision.
Verbatim wording from the response “2) We are producing a Multiple Choice Question (MCQ) assessment of the educational support pack referred to in point 1. This assessment will be rolled out at the end of March 2021 and will be monitored through the clinical supervision structure to ensure that the learning has been cascaded and embedded through all relevant sections of the organisation.” Source location Response from Turning Point
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 Host a clinical session on safe opioid-substitute-treatment prescribing for representatives from every service, supporting subsequent local learning cascades.
Verbatim wording from the response “3) ████████ (Clinical Director) and ████████ (Chief Pharmacist) hosted a clinical session on prescribing Opioid Substitute Treatment (OST) (which includes methadone) safely on Thursday 14 January 2021. In attendance at this session was at least one clinician and one operational representative from every service under the Turning Point umbrella with the aim that that clinician then cascaded the learning within their own service (please see point 4 for further support for this process). Key points from this session included:” Source location Response from Turning Point
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 Publish a clinical brief reminding all clinical staff about safe opioid-substitute-treatment prescribing.
Verbatim wording from the response “4) The Turning Point Public Health and Substance Misuse Senior Clinical Governance Group published within their January 2021 monthly clinical brief a reminder to all clinical staff on prescribing OST safely. I attach a copy of this document for your information. You will see that the key areas included in this brief are relevant to your concerns reflect those as set out in point 3 above.” Source location Response from Turning Point
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out a national audit of medical information available to opioid-substitute-treatment prescribers and documented interim considerations or actions.
Verbatim wording from the response “5) Turning Point will carry out a national audit across all substance misuse services in relation to the medical information available to an OST prescriber at the point of prescription and the documentation of considerations/actions taken pending receipt of background information. This audit will take place in June 2021 to assess the impact of the learning as set out above.” Source location Response from Turning Point
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide every organisational team with an NHS.net email address to enable secure information sharing with NHS bodies and employees.
Verbatim wording from the response “6) We have made arrangements to provide every team within the organisation with an NHS.net email address. The work was completed on 14th October 2020. This ensures that data can be shared securely and efficiently between Turning Point and NHS bodies/employees (such as a GP surgery).” Source location Response from Turning Point
Open published response
6 Nov 2020 Stanley Alfred Babbs · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Lack of prescribing safeguards for patients at higher risk of contrast induced acute kidney injury View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Barking, Havering and Redbridge University Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Barking, Havering and Redbridge University Hospitals NHS Trust
Communicate to radiologists the requirement for personalised assessment of patients receiving intravenous contrast with eGFR below 30 and multiple risk factors.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Record radiologist contrast-authorisation decisions on request forms or the RIS, including decisions for patients with eGFR below 30.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Create a prescription sheet within the PGD for patients with eGFR below 30 or risk factors outside the PGD.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Introduce a radiology request form containing safeguards for abnormal renal function, contrast indication and patient discussion.
View source See 1 more action
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AI-generated summary
Stanley Alfred Babbs · 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
Stanley Alfred Babbs, who had chronic kidney disease, diabetes and heart failure, became unwell after receiving contrast for a CT scan and was diagnosed with contrast-induced acute kidney injury. He was later admitted to hospital and died from sepsis arising from a urinary tract infection on 16 February 2016. The report raised concerns that contrast, a prescription-only medicine, could be administered without a formal prescription, individualised risk/benefit assessment, careful dose consideration or a clearly identified responsible clinician, particularly for patients at high risk of acute kidney injury.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of prescribing safeguards for patients at higher risk of contrast induced acute kidney injury
Wider context from the report “The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it.
The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight.
It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).
The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast. This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.
Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription, evidence of a careful consideration of the dose and a clearly identified responsible clinician.
” Source location Stanley Alfred Babbs · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate to radiologists the requirement for personalised assessment of patients receiving intravenous contrast with eGFR below 30 and multiple risk factors.
Verbatim wording from the response “The following actions have been implemented to ensure safe practice with all patients undergoing a CT scan with IV contrast.” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
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 Record radiologist contrast-authorisation decisions on request forms or the RIS, including decisions for patients with eGFR below 30.
Verbatim wording from the response “The following actions have been implemented to ensure safe practice with all patients undergoing a CT scan with IV contrast.” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
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 Create a prescription sheet within the PGD for patients with eGFR below 30 or risk factors outside the PGD.
Verbatim wording from the response “• Prescriptions for CT IV contrast for patients with eGFR < 30 to ensure these requests are appropriately authorised. (As per action 4 on Plan)” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
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 Introduce a radiology request form containing safeguards for abnormal renal function, contrast indication and patient discussion.
Verbatim wording from the response “• Creating a new Radiology request form to incorporate safeguards for patients with abnormal renal function and to confirm that the clinician has indicated the use of contrast and if a discussion has taken place with the patient about the use of contrast.” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
28 Sep 2020 June Patricia Margaret PARLOUR · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Drug chart design failing to provide clear titration instructions for one-off IV morphine doses View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
June Patricia Margaret PARLOUR · 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
June Parlour was an inpatient with disseminated terminal cancer when she received morphine doses exceeding national and hospital guidelines. Her condition deteriorated, and she later died of opiate toxicity; the overdose significantly hastened her death. Concerns included staff awareness of morphine guidance, inaccurate hospital guidance and incident reporting, education and auditing for doctors, unclear prescribing instructions, and communication and escalation failures between staff.
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 Drug chart design failing to provide clear titration instructions for one-off IV morphine doses
Wider context from the report “5) I was concerned that this incident arose as a result of a doctor and a nurse failing to understanding each other, and the nurse subsequently feeling that she had no choice but to administer an IV dose that she believed to be dangerous, and in particular that:
a) The drug charts design did not facilitate clear instructions for titration for one-off doses of IV morphine .
b) The nurse did not feel confident enough to challenge the prescription (as she perceived it) effectively or escalate / refer to another doctor.
” Source location June Patricia Margaret PARLOUR · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the approved Morphine Prescription sticker across inpatient prescription charts and audit its use.
Verbatim wording from the response “Through a QI process we have developed and approved a new Morphine Prescription sticker for use on prescription charts across all inpatient areas. These are currently out to printers, with a planned roll out programme to take place in December 2020. To close the loop on the QI process this will be subject to audit by the Acute Pain Team.” Source location 2020-0186-Response-from-East-Suffolk-and-North-Essex_Redacted.pdf
Open published response
24 Sep 2020 Eileen Brindley · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3
Failure to avoid prescribing penicillin type antibiotics despite recorded adverse reactions View source Failure to note recorded adverse reactions before prescribing View source Failure to explain prescribing decisions despite recorded adverse reactions View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Tettenhall Medical Practice
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Tettenhall Medical Practice
Review and update the allergy-recording policy to require consistent coding, visible allergy status, reaction severity and reaction descriptions, then provide it to staff.
View source
Tettenhall Medical Practice
Audit all electronically recorded allergic reactions and add available details distinguishing allergy or side effect, timing, severity and symptoms.
View source
Tettenhall Medical Practice
Require clinicians to check documented allergies in the clinical record summary before prescribing.
View source
Tettenhall Medical Practice
Instruct clinicians not to prescribe medication carrying an electronic allergy alert.
View source
Tettenhall Medical Practice
Complete educational updates on prescription errors, prescribing, remote consultations, allergy and anaphylaxis, and pandemic-related change.
View source
Tettenhall Medical Practice
Remind clinicians to make clear and detailed patient-record notes.
View source See 3 more actions
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AI-generated summary
Eileen Brindley · 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
Eileen Brindley, aged 97, was admitted to New Cross Hospital on 28 August 2020 after being found struggling to breathe and died shortly afterwards from anaphylaxis. The concerns included prescribing a penicillin-type antibiotic despite a recorded adverse reaction to Flucloxacillin, without evidence that the prescribing clinician had noted the reaction or explained the prescription, and insufficiently highlighted medical-record entries.
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 avoid prescribing penicillin type antibiotics despite recorded adverse reactions
Wider context from the report “1) That a prescription was issued for a penicillin type antibiotic on 21/8/20 despite an entry in the medical records of the deceased highlighting a previous adverse reaction to Flucloxacillin ;
2) There was no evidence that the prescribing clinician had noted the adverse reaction entry and/or there was no explanation why the medication had been prescribed even if that entry had been noted;
3) The prescription was issued with any consultation either in person or over the telephone;
4) That entries into medical records are not sufficiently highlighted to any clinician who is unfamiliar with the previous medical history of the deceased;
” Source location Eileen Brindley · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to note recorded adverse reactions before prescribing
Wider context from the report “1) That a prescription was issued for a penicillin type antibiotic on 21/8/20 despite an entry in the medical records of the deceased highlighting a previous adverse reaction to Flucloxacillin;
2) There was no evidence that the prescribing clinician had noted the adverse reaction entry and/or there was no explanation why the medication had been prescribed even if that entry had been noted;
3) The prescription was issued with any consultation either in person or over the telephone;
4) That entries into medical records are not sufficiently highlighted to any clinician who is unfamiliar with the previous medical history of the deceased;
” Source location Eileen Brindley · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to explain prescribing decisions despite recorded adverse reactions
Wider context from the report “1) That a prescription was issued for a penicillin type antibiotic on 21/8/20 despite an entry in the medical records of the deceased highlighting a previous adverse reaction to Flucloxacillin;
2) There was no evidence that the prescribing clinician had noted the adverse reaction entry and/or there was no explanation why the medication had been prescribed even if that entry had been noted ;
3) The prescription was issued with any consultation either in person or over the telephone;
4) That entries into medical records are not sufficiently highlighted to any clinician who is unfamiliar with the previous medical history of the deceased;
” Source location Eileen Brindley · Prevention of Future Deaths report
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 and update the allergy-recording policy to require consistent coding, visible allergy status, reaction severity and reaction descriptions, then provide it to staff.
Verbatim wording from the response “4) We have reviewed how allergies are recorded in the medical records. Our discussions focused on the issues generated by this case but included a broader review of coding of all allergies. Following those discussions we have updated our policy ‘Recording Allergies in Patient Records’ and this has been provided to all staff in hard copy and is accessible on a shared computer drive. The key points are:” Source location 2020-0291-Response-from-Tettenhall-Medical-Practice_Redacted-1
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit all electronically recorded allergic reactions and add available details distinguishing allergy or side effect, timing, severity and symptoms.
Verbatim wording from the response “6) The practice is carrying out an extensive audit of all allergic reactions recorded on the electronic record system. This audit is being conducted by one of the administration team with oversight from the Practice Manager. All allergies and side effects are recorded as an ‘adverse reaction’ as this is the only alert code available. However this audit is conducting a review to make sure that wherever possible additional notes are made giving a wider description including, where known, whether the reaction is allergy/side effect, new/historical, mild/severe and symptoms of the reaction such as a rash or breathing difficulties.” Source location 2020-0291-Response-from-Tettenhall-Medical-Practice_Redacted-1
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require clinicians to check documented allergies in the clinical record summary before prescribing.
Verbatim wording from the response “8) All clinicians have been reminded to specifically check allergies documented in the clinical record summary before prescribing for any patient.” Source location 2020-0291-Response-from-Tettenhall-Medical-Practice_Redacted-1
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Instruct clinicians not to prescribe medication carrying an electronic allergy alert.
Verbatim wording from the response “9) Clinicians have been instructed never to prescribe any medication which has an electronic alert indicating the patient has an allergy.” Source location 2020-0291-Response-from-Tettenhall-Medical-Practice_Redacted-1
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete educational updates on prescription errors, prescribing, remote consultations, allergy and anaphylaxis, and pandemic-related change.
Verbatim wording from the response “11) ████████ has completed various educational updates including a MIMS course on avoiding prescription errors, RCGP course on prescribing, MDU course on remote consultation skills, MIMS course on allergy and anaphylaxis and BMJ course on tips for coping with change during a pandemic.” Source location 2020-0291-Response-from-Tettenhall-Medical-Practice_Redacted-1
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind clinicians to make clear and detailed patient-record notes.
Verbatim wording from the response “13) Reminder has been made to all clinicians always to make clear and detailed notes in the patient records.” Source location 2020-0291-Response-from-Tettenhall-Medical-Practice_Redacted-1
Open published response
23 Sep 2020 Mrs Christine Forbes · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1
Failure to ensure clinicians know patients' full medical history before treating and prescribing View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mrs Christine Forbes · 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
Mrs Christine Forbes, a 72-year-old woman with a history of oxycodone stockpiling and misuse, died on 2 February 2020 after taking oxycodone and zolpidem. The principal concern was that patients registering with GP surgeries may be prescribed medication before their medical notes and relevant history are available.
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 ensure clinicians know patients' full medical history before treating and prescribing
Wider context from the report “1. That when patients register at GP surgeries (across England) they do so without their medical notes and history. This material can take a significant amount of time to be sent to a GP practice after a request is sent to Primary Care Support England. Doctors and other medical practitioners are therefore treating and prescribing in situations where a full medical history is not known .
” Source location Mrs Christine Forbes · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enable all Derby and Derbyshire general practices to use GP2GP electronic record transfer.
Verbatim wording from the response “All general practices across Derby and Derbyshire are enabled for GP2GP electronic record transfer; this is an electronic system which allows patients' electronic health records to be transferred between their old and new practices within a matter of minutes (at most 24hrs) , when a patient registers with a new GP practice.” Source location 2020-0181-Response-from-NHS-Derby-and-Derbyshire-Clinical-Commissioning-Group-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Offer Ashbourne Medical Practice additional GP2GP and electronic record transfer training.
Verbatim wording from the response “• Offer additional GP2GP/ Record Transfer training to Ashbourne Medical Practice” Source location 2020-0181-Response-from-NHS-Derby-and-Derbyshire-Clinical-Commissioning-Group-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Offer Ashbourne Medical Practice additional note summarisation training.
Verbatim wording from the response “• Offer additional training Note Summarisation to Ashbourne Medical Practice” Source location 2020-0181-Response-from-NHS-Derby-and-Derbyshire-Clinical-Commissioning-Group-Redacted.pdf
Open published response
28 Feb 2020 Irene Whittingham · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure of prescribing software dropdown controls to prevent selection of excessive twice-daily loading doses View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Irene Whittingham · 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
Irene Whittingham died at The Royal Bolton Hospital on 31 July 2019 from the toxic effects of a Vitamin D overdose. An incorrect discharge prescription recorded Vitamin D as twice daily, and no monitoring advice was provided while she was taking high doses in the community. Concerns included conflicting guidance on blood-level monitoring and software dropdown options that permitted a potentially unsafe dosage.
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 prescribing software dropdown controls to prevent selection of excessive twice-daily loading doses
Wider context from the report “3. The WellSky and EMIS Software, had a confusing user drop down menu option , which allowed the user to click on a twice daily dose despite the loaded dosage, exceeding national guidelines .
” Source location Irene Whittingham · Prevention of Future Deaths report
Open source report
27 Jan 2020 Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to reconsider adrenaline auto injector dose after switching device View source
This report raised 20 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
National Institute for Health and Care Excellence NHS Enfield Clinical Commissioning Group NHS England the three G.Ps that were interested persons in the above matter
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
NHS Enfield Clinical Commissioning Group
Disseminate prescribing, dosing, device-change and training guidance for adrenaline auto-injectors through safety bulletins, newsletters, intranet updates, scriptswitch messages and practice events.
View source
NHS Enfield Clinical Commissioning Group
Follow up practices through meetings and training, and collate records confirming patient device training and dosage reviews.
View source
NHS Enfield Clinical Commissioning Group
Require senior pharmacist approval of scriptswitch messages and GP Clinical Lead approval of newsletters before distribution.
View source
NHS Enfield Clinical Commissioning Group
Establish an NCL primary care group to review local formulary and scriptswitch messaging and standardize messages across CCGs.
View source
NHS Enfield Clinical Commissioning Group
Implement a post-incident review, produce a report, and submit it to the Quality and Safety Committee to oversee recommendations and implementation.
View source
the three G.Ps that were interested persons in the above matter
Audit AAI patients’ prescribed doses and contact patients to confirm correct devices, usage knowledge and storage advice.
View source
the three G.Ps that were interested persons in the above matter
Process AAI prescriptions as acute prescriptions and provide device-specific safety instructions covering appropriate dosing, carrying two pens and emergency action.
View source
the three G.Ps that were interested persons in the above matter
Appoint a Practice Anaphylaxis Champion to oversee staff awareness, training, prescribing surveillance, protocol adherence and patient reviews.
View source
the three G.Ps that were interested persons in the above matter
Amend the ScriptSwitch message with AAI availability, prescribing, dose-checking, counselling, training and allergy-action-plan requirements.
View source
NHS England
Have commissioning teams liaise with relevant organisations to facilitate uptake of new guidance and resources supporting management of severe allergies.
View source
NHS England
Consider whether communication routes or commissioning levers can support uptake and embedding of new allergy guidance and resources.
View source See 8 more actions
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AI-generated summary
Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Shanté Andrée Marie Turay-Thomas ate hazelnuts on 18 September 2018 and died soon afterwards from acute anaphylaxis. The report identifies concerns about inadequate allergy care, advice and training concerning adrenaline auto-injectors, prescribing and clinical communication, and errors in the NHS 111 response and ambulance categorisation.
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 reconsider adrenaline auto injector dose after switching device
Wider context from the report “5. When Shanté’s AAI was changed from an EpiPen to an Emerade, her GPs failed to reconsider the prescription and to increase her dose from 300mgs to 500mcgs .
” Source location Shanté Andrée Marie TURAY-THOMAS · 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 Disseminate prescribing, dosing, device-change and training guidance for adrenaline auto-injectors through safety bulletins, newsletters, intranet updates, scriptswitch messages and practice events.
Verbatim wording from the response “1. The narrative verdict was discussed at the NCL Medication Safety Officer (MSO) Local Network on 17th January 2020. The network agreed that a Medicines Safety Bulletin on Adrenaline Auto Injectors (AAIs) would be distributed to GPs and other primary care healthcare professionals. The NCL Medicines Safety Bulletin on Adrenaline Auto Injectors (AAI) dated 24th January 2020 is attached as appendix 1. The bulletin was approved virtually by one NCL Medication Safety Officer (MSO) Local Network following the meeting on 17th January 2020 and distributed to Enfield GP practices on 30th January 2020.” Source location 2020-0124-Response-from-Enfield-CCG.pdf
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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 Follow up practices through meetings and training, and collate records confirming patient device training and dosage reviews.
Verbatim wording from the response “CCG pharmacists to check what action they have taken regarding the NCL Medicines Safety Bulletin on Adrenaline Auto Injectors (AAI) have contacted all GP practices. This is being followed up with individual practice meetings, training meetings for GPs, training sessions for Primary Care Network pharmacists, and by CCG pharmacists working in practices. A record is in the process of being collated to capture actions by individual practices to ensure all patients regularly receive appropriate training in the use of their device and dosages have been reviewed. This process is due to complete by 30th April 2020.” Source location 2020-0124-Response-from-Enfield-CCG.pdf
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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 Require senior pharmacist approval of scriptswitch messages and GP Clinical Lead approval of newsletters before distribution.
Verbatim wording from the response “An analysis of CCG actions that may have been contributory to this incident were lack of governance around scriptswitch messaging and newsletters sent to practices from the CCG Medicines Management team. Following the review of this case, it was identified that a more robust governance and decision making process was needed. Current measures to stop any recurrence include:” Source location 2020-0124-Response-from-Enfield-CCG.pdf
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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 Establish an NCL primary care group to review local formulary and scriptswitch messaging and standardize messages across CCGs.
Verbatim wording from the response “NCL primary care group has been set up to review the local formulary and scriptswitch messaging to standardize messages across NCL CCGs.” Source location 2020-0124-Response-from-Enfield-CCG.pdf
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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 Implement a post-incident review, produce a report, and submit it to the Quality and Safety Committee to oversee recommendations and implementation.
Verbatim wording from the response “The CCG will now implement a post incident review and a report will be completed to ensure that all actions identified are implemented to prevent a recurrence of this nature. This will include a review of governance processes and decision-making points. This report will go to the Quality and Safety Committee, which will oversee any recommendations and ensure implementation of all actions.” Source location 2020-0124-Response-from-Enfield-CCG.pdf
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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 Audit AAI patients’ prescribed doses and contact patients to confirm correct devices, usage knowledge and storage advice.
Verbatim wording from the response “1. Following Ms Turay-Thomas’ death, the Practice undertook an audit in October 2019 of all patients who were being prescribed Emerade to ensure that the dosage was in accordance with the BNF based on the respective patients’ weight and age. Indeed, all patients who use AAI pens have had their doses reviewed. Patients have been contacted to ensure that they have the correct dose and appropriate knowledge about the use and storage of the pen. Letters were sent to patients on Emerade, which included up to date advice from the MHRA in July 2019, December 2019 and March 2020. In respect of patients taking Jext and Epipen, letters were sent to them in January 2020.” Source location 2020-0124-Response-from-Radcliffes-Le-Brasseur_Redacted.pdf
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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 Process AAI prescriptions as acute prescriptions and provide device-specific safety instructions covering appropriate dosing, carrying two pens and emergency action.
Verbatim wording from the response “2. All prescriptions for AAIs are now dealt with as acute prescriptions, as opposed to repeat prescriptions. This ensures that each prescription is scrutinised in detail to ensure that the type of pen and dose of adrenaline is appropriate for the patient. On the face of any AAI prescription, it is expressly stated for the avoidance of any doubt that a patient should carry two AAI pens on their person at all times and ensure that they are familiar with the use of the pen. There is also some safety netting advice in the event of an emergency. We have enclosed a sample prescription to illustrate this change. In addition, each prescription is accompanied by an AAI brand specific letter to the patient providing the most important details about the AAI pens to enable a patient to use it safely and effectively. We have also enclosed a copy of a standard letter in this regard.” Source location 2020-0124-Response-from-Radcliffes-Le-Brasseur_Redacted.pdf
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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 a Practice Anaphylaxis Champion to oversee staff awareness, training, prescribing surveillance, protocol adherence and patient reviews.
Verbatim wording from the response “9. The Practice has undertaken a rigorous review of all patients that have been prescribed AAI pens so as to ensure that the correct dose and pen is being prescribed. The Practice has nominated one of the Pharmacists to act as the ‘Practice Anaphylaxis Champion.’ This role will include ensuring staff awareness, training and regular surveillance of appropriate prescribing practices and adherence to practice protocols. The Pharmacist will also contact all patients prescribed AAIs to undertake regular reviews of their condition, treatment and training.” Source location 2020-0124-Response-from-Radcliffes-Le-Brasseur_Redacted.pdf
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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 Amend the ScriptSwitch message with AAI availability, prescribing, dose-checking, counselling, training and allergy-action-plan requirements.
Verbatim wording from the response “11. The Practice has shared learning with the CCG medicine management team and the message on scriptswitch has been amended as follows:” Source location 2020-0124-Response-from-Radcliffes-Le-Brasseur_Redacted.pdf
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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 Have commissioning teams liaise with relevant organisations to facilitate uptake of new guidance and resources supporting management of severe allergies.
Verbatim wording from the response “• I will ensure your report is sent to HEE and the Royal College of General Practitioners. Our commissioning teams will liaise directly with all relevant organisations to facilitate uptake of any new guidance and resource that would support better management of people with severe allergies.” Source location 2020-0124-Response-from-NHS-England_Redacted.pdf
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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 Consider whether communication routes or commissioning levers can support uptake and embedding of new allergy guidance and resources.
Verbatim wording from the response “We are deeply saddened by Shante’s death. We are grateful to have had the opportunity to respond to your concerns relevant to NHSEI. We will continue to work with HEE, the professional Royal Colleges and the other organisations addressed in your report to keep abreast of any new guidance or resources that they produce that would support better management of people with severe allergies. We will consider whether any of our communication routes or commissioning levers can help with their uptake and embedding.” Source location 2020-0124-Response-from-NHS-England_Redacted.pdf
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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 Matters of concern 1–14 and 20 do not concern NHS Pathways and fall outside its remit.
Verbatim wording from the response “HM Coroner raised matters of concern numbered 1 - 20 in the PFD report. Matters of concern 1 – 14 and 20 are not applicable to NHS Pathways. We set out below our response to matters of concern 15 to 19.” Source location 2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
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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 Information about specific adrenaline auto-injector doses is a prescriber’s responsibility, not the call handler’s.
Verbatim wording from the response “Information about the specific dose required in respect of each AAI has not been included. This is because the appropriate dose is a matter for the prescriber, not the call handler issuing system-generated instructions on how to administer the medication.” Source location 2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
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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 BNF and BNFc advice sufficiently covers adrenaline auto-injector doses, quantities and training, so NICE will not duplicate that advice.
Verbatim wording from the response “Having reviewed your concerns, we consider that the British National Formulary (BNF) and the BNF for Children (BNFc) already contain detailed advice on these aspects of care, including the following pieces of MHRA/CHM advice from 2017 and 2019, in the section on Adrenaline/Epinephrine (https://bnf.nice.org.uk/drug/adrenalineepinephrine.html):” Source location 2020-0124-Response-from-NICE_Redacted.pdf
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30 Oct 2019 Mrs Annie Lloyd · Prevention of Future Deaths report Black Country
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Concerns raised 1
Failure to independently verify warfarin dosage before prescribing View source
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AI-generated summary
Mrs Annie Lloyd · 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
Mrs Annie Lloyd was taking warfarin and appears to have taken a higher-than-intended dose for around two weeks. She was found unconscious on 6 April 2019 with a large subdural haematoma and raised intracranial pressure, and died the same day. Concerns identified during the inquest included inadequate checking of her warfarin dosage and reliance on family members to confirm the required dose.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to independently verify warfarin dosage before prescribing
Wider context from the report “1. Evidence emerged during the inquest that there was an inadequate process in place for checking the patient’s warfarin level dosage . It appears that a “yellow book” confirming the dosage was being copied and the GP issued the prescription without checking this .
2. The GP practice claim to have placed reliance on the family to confirm the dosage required .
” Source location Mrs Annie Lloyd · 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 Require Warfarin patients to present yellow books, record and verify INR results and doses, and confirm prescriptions before issuing them.
Verbatim wording from the response “1. All of our patients (who take Warfarin) have been told that they must bring in their yellow Warfarin book every time they go to have their INR checked at the hospital. The Warfarin book will be scanned and then given to the practice manager who will code the latest INR. She will then enter on to their consultation the date the INR was taken, the result, what dose of medication they should be taking and when their next INR is due. She will then request the correct strength as per the yellow Warfarin book. The General Practitioner will also check the details before issuing the prescription.” Source location 2019-0493-Response-by-Brace-Street-Health-Centre
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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 Implement a written procedure for prescribing Warfarin, checking INR results, and changing doses.
Verbatim wording from the response “3. The Practice now has a written Procedure for the process of prescribing Warfarin, checking INR results and altering doses. Please find this document attached.” Source location 2019-0493-Response-by-Brace-Street-Health-Centre
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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 Assign the assistant practice manager to check Warfarin requests during the practice manager’s leave.
Verbatim wording from the response “a) The assistant practice manager will check Warfarin requests when the practice manager is on leave.” Source location 2019-0493-Response-by-Brace-Street-Health-Centre
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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 Warfarin prescribing, monitoring and auditing systems are considered robust and sufficient to prevent further recurrences.
Verbatim wording from the response “The receptionist will photocopy and scan the yellow book immediately and then give it to the practice manager who will code the latest INR and check the correct dose. The GP will then check it again. Our pharmacist is doing a quarterly audit to make sure we are not missing any patients.” Source location 2019-0493-Response-by-Brace-Street-Health-Centre
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10 Oct 2019 Abdeslam BENELGHAZI · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1
Unsafe co-prescribing of clonazepam with methadone View source
Linked response
Department of Health and Social Care
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
Department of Health and Social Care
Request marketing authorisation holders to update clonazepam and methadone product information, including warnings about respiratory depression and delayed methadone effects.
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Department of Health and Social Care
Remind healthcare professionals through a Drug Safety Update article about respiratory-depression risks when benzodiazepines and opioids are co-prescribed.
View source
Department of Health and Social Care
Ensure development of a mental-health early-warning-score case study covering opioid use and over-sedation.
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Department of Health and Social Care
Develop prescribing guidance for mental health, endorsed by the Royal Pharmaceutical Society, with additional support, resources and learning materials.
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AI-generated summary
Abdeslam BENELGHAZI · 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
Abdeslam BENELGHAZI was detained under Section 2 of the Mental Health Act and was prescribed methadone alongside several other medications, including clonazepam. He died on 9 December 2017; the inquest identified concerns about inappropriate combined prescribing, inadequate monitoring and failure to escalate concerns, including after signs of over-sedation or reduced consciousness.
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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 Unsafe co-prescribing of clonazepam with methadone
Wider context from the report “He expressed a particular concern in relation to the prescribing of clonazepam with methadone . The reasons he gave were that clonazepam has a long half life; side effects include respiratory depression ; that one supplier of clonazepam states “concomitant use of clonazepam with opioids may result in sedation, respiratory depression, coma and death ”; that clonazepam is a means of delivering a high equivalent dose benzodiazepine without exceeding BNF limits .
He said that in this case clonazepam may have been the drug that tipped the balance.
” Source location Abdeslam BENELGHAZI · 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 Request marketing authorisation holders to update clonazepam and methadone product information, including warnings about respiratory depression and delayed methadone effects.
Verbatim wording from the response “The MHRA has reviewed all licences for clonazepam and methadone and noted that not all marketing authorisation holders (MAH) have applied the appropriate amendments. The MHRA is therefore contacting the MAH holders to request updates to the product information and the outstanding changes are expected to be implemented within three to six months.” Source location 2019-0337-Response-by-Department-of-Health-and-Social-Care
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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 Remind healthcare professionals through a Drug Safety Update article about respiratory-depression risks when benzodiazepines and opioids are co-prescribed.
Verbatim wording from the response “In addition, the MHRA will remind healthcare professionals of the risks of respiratory depression when benzodiazepines and opioids are co-prescribed via an article in its Drug Safety Update early this year.” Source location 2019-0337-Response-by-Department-of-Health-and-Social-Care
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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 Ensure development of a mental-health early-warning-score case study covering opioid use and over-sedation.
Verbatim wording from the response “In response to changes to the National Early Warning Score (NEWS) parameters¹¹, Health Education England (HEE) is working in partnership with NHS England and NHS Improvement and others, to support learning needs for the health and care workforce. Learning resources have either been developed, are in development or are being planned for staff working in secondary care, primary care, ambulance settings and mental health settings. The resources consist of a number of case studies covering presentations common to particular care settings. In response to your report, HEE advises that it will ensure the development of a specific case study to cover opioid use and over sedation when it develops the early warning score learning resource for mental health settings.” Source location 2019-0337-Response-by-Department-of-Health-and-Social-Care
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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 Develop prescribing guidance for mental health, endorsed by the Royal Pharmaceutical Society, with additional support, resources and learning materials.
Verbatim wording from the response “I am further advised that HEE is providing education and training opportunities for mental health practitioners through the development of related competency frameworks and teaching initiatives. HEE is working with health system stakeholders, subject matter experts and people with lived experience, to develop guidance, endorsed by the Royal Pharmaceutical Society, that sets out additional guidance, support, resources and learning materials specifically related to prescribing in mental health.” Source location 2019-0337-Response-by-Department-of-Health-and-Social-Care
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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 Clinicians are responsible for prescribing decisions, including medication dosages and combinations.
Verbatim wording from the response “Prescribing decisions are made by clinicians who are responsible for taking into consideration the dosage of medication prescribed and the combination of medicines administered.” Source location 2019-0337-Response-by-Department-of-Health-and-Social-Care
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.