Recurring concern

Unsafe medication prescribing

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First reported 5 May 2013•Latest report 25 Jun 2026

Definition

What this concern includes

Includes failures involving the clinical appropriateness of prescribing or medication selection, including inadequate assessment of indication, patient circumstances, relevant information, alternatives or dose.

Not included

Excludes failures limited to medication administration after an otherwise appropriate prescription.
Excludes generic documentation, training or communication deficiencies unless they directly result in or are explicitly tied to an unsafe prescribing decision.
Excludes dispensing, supply or monitoring failures that do not concern whether the medication prescription itself was clinically appropriate.

Reports: 121
Individual concerns: 151
Date range: 2013–2026
Stated actions: 246

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care20

NHS England16

Care Quality Commission7

NHS Greater Manchester Integrated Care Board7

General Medical Council6

National Institute for Health and Care Excellence4

Recipient name withheld4

Medicines and Healthcare products Regulatory Agency3

NHS Surrey and Sussex Integrated Care Board3

Royal College of General Practitioners3

Royal College of Physicians3

University Hospitals Birmingham NHS Foundation Trust3

Welsh Government3

BNF Publications2

Cwm Taf Morgannwg University Local Health Board2

Concerns and responses across reports

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

5 Nov2018
London Inner South
Concerns raised2
1. Medication prescribing errors involving incorrect doses
2. Inappropriate prescribing of large medication quantities during an initial medication switch
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Name not published · 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

The deceased died at St Thomas’s Hospital on 22 November 2017 from brain damage sustained after he hanged himself at home on 20 November 2017. Concerns included changes and prescribing of psychiatric and sedative medication, inadequate clinical records and review of past records, failure to make an urgent psychiatric referral, and uncertainty about the medication found after his death and what he had taken.

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
Medication prescribing errors involving incorrect doses
Wider context from the report
“3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP. 4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose. 5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full. 6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance. 7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017. 8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing. 9. I accepted ████████ opinion on the various issues set out above. 10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when. ”
Source location
Name not published · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inappropriate prescribing of large medication quantities during an initial medication switch
Wider context from the report
“3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP. 4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose. 5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full. 6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance. 7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017. 8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing. 9. I accepted ████████ opinion on the various issues set out above. 10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when. ”
Source location
Name not published · Prevention of Future Deaths report
Page 1 · concerns
Open source report
24 Oct2018
Inner West London
Concerns raised2
1. Failure to access the patient’s medical records before prescribing potentially dangerous and addictive drugs
2. Failure to contact the patient’s regular medical practitioner before prescribing potentially dangerous and addictive drugs
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Ensure NHS online consultations provide safe, secure access to an appropriate clinician connected with the patient’s GP practice.
  Stated by NHS EnglandStated planned
Respondent positions 2
1. Position
  The death appears unrelated to NHS services because the consultation, prescription and medication were obtained outside the NHS.
  Stated by NHS EnglandDisputes the concern
1. Position
  CQC and MHRA are better placed to explain and address online prescribing safety work.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Jennifer Anne Lacey · 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

Jennifer Anne Lacey was found deceased in a hotel room in Morden on 4 June 2018, having consumed a large amount of alcohol and 210 tramadol tablets. The concerns were that potentially dangerous and addictive drugs were freely available over the internet, could be prescribed without contact with the patient’s regular doctor or access to medical records, and might be dispensed by UK pharmacies without further checks.

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 access the patient’s medical records before prescribing potentially dangerous and addictive drugs
Wider context from the report
“1. That such potentially dangerous and addictive drugs are so freely available over the internet. 2. That they can be prescribed without any contact with the patient’s regular medical practitioner or access to the patient’s medical records. 3. That such prescriptions of such potentially dangerous and addictive drugs may be being filled in UK pharmacies without any further checks. ”
Source location
Jennifer Anne Lacey · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to contact the patient’s regular medical practitioner before prescribing potentially dangerous and addictive drugs
Wider context from the report
“1. That such potentially dangerous and addictive drugs are so freely available over the internet. 2. That they can be prescribed without any contact with the patient’s regular medical practitioner or access to the patient’s medical records. 3. That such prescriptions of such potentially dangerous and addictive drugs may be being filled in UK pharmacies without any further checks. ”
Source location
Jennifer Anne Lacey · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Ensure NHS online consultations provide safe, secure access to an appropriate clinician connected with the patient’s GP practice.

Verbatim wording from the response
“These issues are important for NHS England and we will ensure that NHS online consultations provide a safe and secure way for patients to discuss their health concerns with an appropriate clinician connected to their own GP practice and place centred around their needs. NHS England has adopted a robust system of quality assurance, safety and security standards so that patients and clinicians can feel confident in using online consultations.”

Source location
2018-0315-Response-by-NHS-England
Page 2 · response
Published 23 February 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The death appears unrelated to NHS services because the consultation, prescription and medication were obtained outside the NHS.

Verbatim wording from the response
“With regard to this case, and based on the information provided within the Regulation 28, it appears that this death was not the result of services provided by NHS, but from services outside of the NHS. It is unclear whether this doctor or company were registered and the site from which the deceased obtained the consultation, prescription and medication. Nevertheless, the provision of remote consultations and the supply of medicines through distance selling remains a concern. We are working with other health regulators who have a greater role in responding to this challenge.”

Source location
2018-0315-Response-by-NHS-England
Page 3 · response
Published 23 February 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
CQC and MHRA are better placed to explain and address online prescribing safety work.

Verbatim wording from the response
“NHS England remains committed to improving the safety of controlled drugs and online prescribing. We will continue to work across the system with key partners nationally, regionally and locally to ensure patient safety. We would also suggest that contact is made directly with the CQC and MRHA would be better placed should you wish to understand the work in this area further.”

Source location
2018-0315-Response-by-NHS-England
Page 3 · response
Published 23 February 2019
Open published response
30 Aug2018
West Yorkshire Eastern
Concerns raised1
1. Failure to follow senior clinician anticoagulant-duration advice
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Record post-discharge Tinzaparin instructions on electronic drug charts and transfer them automatically to electronic discharge advice notes for eligible patients.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
Respondent positions 2
1. Position
  The Trust determined that Tinzaparin was correctly prescribed under NICE guidance, and a longer course could not be shown to have prevented death.
  Stated by Leeds Teaching Hospitals NHS TrustDisputes the concern
1. Position
  Comprehensively reviewing the entire medical record before electronic discharge prescribing is considered impractical for junior doctors.
  Stated by Leeds Teaching Hospitals NHS TrustUnable to act
AI-generated summary

Michael John Drewell · 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

Michael John Drewell fell from his bike while travelling to work on 16 November 2017, sustained a hip fracture, and underwent surgery. He later suffered a cardiac arrest at home and died on 22 December 2017 from a pulmonary thromboembolism, likely a complication of the hip surgery. The concerns were that a Senior Clinician’s advice for six weeks of Tinzaparin was not followed and was not recorded in the electronic notes, resulting in a four-week prescription that ended two days before his death.

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 follow senior clinician anticoagulant-duration advice
Wider context from the report
“The treating Consultant advised that Mr Drewell, because of his height and weight, be given anti-coagulant Tinzaparin for six weeks rather than four weeks as was usual. He recorded his advice on the handwritten records at hospital following a ward round the day after surgery. When the Junior Doctor came to prescribe Tinzaparin several days later he likely did not consult the handwritten notes and only prescribed four weeks Tinzaparin immediately before Mr Drewell’s discharge from hospital. Evidence was heard that Junior Doctors would not be expected to consult the handwritten notes when prescribing drugs in accordance with NICE Guidelines. It is of concern that the advice of a Senior Clinician was not followed and, further, that his advice was not placed upon the electronic notes. ”
Source location
Michael John Drewell · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Record post-discharge Tinzaparin instructions on electronic drug charts and transfer them automatically to electronic discharge advice notes for eligible patients.

Verbatim wording from the response
“I can reassure you that good practice is already embedded within many clinical areas throughout the Trust. For example, Elderly Medicine patients with pelvic fractures who are being discharged to care in the community (CIC) beds have Tinzaparin continued until they are weight bearing after discharge. An instruction to this effect is added to the electronic drug chart and this information is then pulled through automatically to the EDAN. In addition, our pharmacists will also add electronic notes regarding discharge medication advice following multi-disciplinary team meetings with treating clinicians.”

Source location
2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 26 September 2018
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Trust determined that Tinzaparin was correctly prescribed under NICE guidance, and a longer course could not be shown to have prevented death.

Verbatim wording from the response
“At the inquest it was accepted that it was not possible to say that the ending of the prescription more than minimally contributed to his death. The Trust provided a root cause analysis summary that concluded that the correct dose of Tinzaparin had been prescribed for a gentleman of Mr Drewell’s height and weight and that there had been no lapses in care. Tinzaparin was prescribed at discharge according to NICE guidance. The trust has therefore determined that, notwithstanding the request by an individual consultant, Tinzaparin was correctly prescribed for Mr Drewell and it is not possible to say that a longer course of the anticoagulant would have prevented his death.”

Source location
2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 26 September 2018
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Comprehensively reviewing the entire medical record before electronic discharge prescribing is considered impractical for junior doctors.

Verbatim wording from the response
“In your Regulation 28 Report you highlight the fact that the junior doctor did not consult the hand-written medical records before prescribing the anticoagulant medication. I am sure that you will agree that it is impractical for junior doctors to comprehensively review the medical record in its entirety when completing the electronic discharge advice note (EDAN) and prescription. It is therefore imperative that if individual clinicians decide to prescribe ‘off protocol’ they either action this themselves personally, or leave clear unambiguous instructions within the electronic record. This can be done in two ways; either the eMeds electronic prescribing chart can be annotated or the EDAN can be pre-populated with specific discharge advice.”

Source location
2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 26 September 2018
Open published response
8 Aug2018
Manchester North
Concerns raised1
1. Lack of guidance for clinicians on prescribing highly addictive and potentially harmful drugs alongside one another
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review opioid medicines product information and seek expert advice on benefit-risk and regulatory recommendations.
  Stated by Medicines and Healthcare products Regulatory AgencyStated in progress
AI-generated summary

Ian Paul Wolstenholme · 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

Ian Paul Wolstenholme was found collapsed at home on 17 December 2017 and died later that day. The medical cause of death was combined drug toxicity, with liver cirrhosis and diabetes mellitus also contributing. The report raised concern about the lack of guidance for prescribing highly addictive and potentially harmful drugs together, particularly in cases of polypharmacy.

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 guidance for clinicians on prescribing highly addictive and potentially harmful drugs alongside one another
Wider context from the report
“1. During the course of the evidence, it became apparent that there is no guidance – national or otherwise - available to Clinicians such as GPs, Hospital doctors etc. on the how best to approach the prescribing of highly addictive and potentially very harmful drugs alongside one another. In this case, the deceased had been legitimately prescribed three different types of neuropathic analgesia (including Pregabalin), alongside other opiate based medications. Whilst such drugs are almost always prescribed for very good clinical reason/s, this type of polypharmacy gives rise to the potential risk of serious harm/death. I believe that guidance would help to prevent future deaths from combined drug toxicity. ”
Source location
Ian Paul Wolstenholme · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review opioid medicines product information and seek expert advice on benefit-risk and regulatory recommendations.

Verbatim wording from the response
“You will be interested to note that the MHRA is currently undertaking a review of the product information for all opioid medicines and will be seeking the advice of an Expert Working Group of the Commission on Human Medicines. The Expert Working Group will consider the benefit risk of opioid-containing medicines and make recommendations for regulatory action to better support appropriate use of prescription opioids, including educational initiatives to ensure awareness of risks for both patients and healthcare professionals.”

Source location
2018-0272-Response-by-Department-of-Health
Page 2 · response
Published 30 October 2018
Open published response
1 Aug2018
Isle of Wight
Concerns raised3
1. Failure to check the medicines database before prescribing duplicate medication doses
2. Failure to prevent inappropriate continuing prescriptions of Fondaparinux and Ticagrelor
3. Failure to prescribe aspirin at the standard continuing dose
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Cuthbert Anthony Stanley Hingert · 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

Cuthbert Anthony Stanley Hingert was admitted to hospital with shortness of breath and possible acute coronary syndrome, during which duplicate doses of antiplatelet and anticoagulant medications were given. He later became confused, fell and sustained a subdural haematoma, skull fracture and subarachnoid haemorrhage, dying in hospital on 5 March 2017. Concerns included failures to check the medicines database, inappropriate or potentially inappropriate prescribing, delayed documentation, inadequate staff training and failure to report a medication incident according to protocol.

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 check the medicines database before prescribing duplicate medication doses
Wider context from the report
“1. The evidence revealed that the Medical Registrar did not check the JAC medicines database to see that Mr Hingert had already been administered a stat dose of antiplatelets and anticoagulant medication before prescribing second dose of these medications. ”
Source location
Cuthbert Anthony Stanley Hingert · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to prevent inappropriate continuing prescriptions of Fondaparinux and Ticagrelor
Wider context from the report
“3. Mr Hingert had already been prescribed continuing doses of Fondaparinux and Ticagrelor, which (fortuitously) were not administered. ”
Source location
Cuthbert Anthony Stanley Hingert · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to prescribe aspirin at the standard continuing dose
Wider context from the report
“2. The Medical Registrar prescribed aspirin to continue at 300mg rather than at the standard dose of 75mg daily. ”
Source location
Cuthbert Anthony Stanley Hingert · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Jul2018
West Yorkshire (Western)
Concerns raised1
1. Potentially unsafe clomipramine prescribing practices
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Existing product information and NICE guidance provide monitoring and toxicity-risk controls; routine clomipramine blood-level screening is not currently recommended.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
AI-generated summary

Kathleen Gabrielle Bamforth · 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

Kathleen Gabrielle Bamforth was found unresponsive at home on 28 May 2017 and was confirmed to have died after resuscitation attempts. The cause of death was recorded as the effects of clomipramine toxicity, although the circumstances of the toxicity remained unclear. The substantive concerns were about reviewing prescribing guidelines for clomipramine and considering routine blood screening for patients receiving it long term.

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
Potentially unsafe clomipramine prescribing practices
Wider context from the report
“• To review current practice guidelines with respect to the prescription of clomipramine • To consider the merits of routine blood screens in patients prescribed with long term use of clomipramine. ”
Source location
Kathleen Gabrielle Bamforth · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing product information and NICE guidance provide monitoring and toxicity-risk controls; routine clomipramine blood-level screening is not currently recommended.

Verbatim wording from the response
“On the matter of clinical guidelines, NICE has advised that its guidelines set out the expectation that prescribers will use a drug's Summary of Product Characteristics (SmPC), as well as the 'British National Formulary' (BNF) to inform decisions made with individual patients.”

Source location
2018-0247-Response-by-Department-of-Health
Page 1 · response
Published 24 September 2018
Open published response
29 Jun2018
Suffolk
Concerns raised1
1. Failure to accurately transcribe intended steroid doses when rewriting drug charts
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

DAPHNE JOAN PENN · 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

Daphne Joan Penn was transferred to Newmarket Community Hospital for rehabilitation and later died after readmission to West Suffolk Hospital, following deterioration. The inquest recorded pneumonia as the cause of death and identified concerns about an inadvertently rapid reduction in her long-term steroid therapy, delays in communicating family concerns, and a prescribing error that caused an additional reduction in the steroid dose.

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 accurately transcribe intended steroid doses when rewriting drug charts
Wider context from the report
“The inquest also heard that a more rapid steroid reduction rate than that suggested by the original consultant was initiated, although the clinical reasons for this were given by the second consultant in respect of the need to balance benefits against the risk of further gastro-intestinal bleeding here; that there was a delay transmitting to relevant medical staff concerns about her condition expressed to healthcare staff by Mrs Penn’s very supportive family, who clearly understood the issues related to steroids well; and that there was also an inadvertent additional decrease in the steroid dose prescribed following a prescribing error by a general medical practitioner who misread the intended steroid dose when rewriting the drug chart. ”
Source location
DAPHNE JOAN PENN · Prevention of Future Deaths report
Page 1 · concerns
Open source report
15 Jun2018
Brighton and Hove
Concerns raised1
1. Failure to apply adequate safeguards when prescribing potentially dependence-forming or misused medication
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 19
1. Action
  Discuss discharge-information requirements with Emergency Department medical staff through regular governance meetings.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Increase staff awareness of frequent requests for small medication quantities as potential risk indicators.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
3. Action
  Audit records of patients receiving Zopiclone and review their prescribed quantities.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
1. Action
  Review high-risk prescribing records and remove online prescription-request access for weekly, controlled, dependency-forming and potentially abusive medicines.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
2. Action
  Provide protected administrative and clinical staff time to manage prescription requests.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
3. Action
  Discuss sharing the high-risk medication review protocol with a linked practice.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated in progress
4. Action
  Lower computer-alert thresholds for early prescription ordering and increase awareness of relevant alerts.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
5. Action
  Embed the high-risk drug review protocol with support from the Medication Management team.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated in progress
6. Action
  Ensure the new Practice Repeat Prescribing Policy covers current best practice.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated in progress
7. Action
  Audit Zopiclone prescribing to verify repeat-template intervals, doses and limits, and reduce some prescription amounts.
  Stated by North Laine Medical CentreStated completed
8. Action
  Remove online prescription requests for controlled drugs and drugs of potential abuse or dependence, following patient assessment.
  Stated by North Laine Medical CentreStated in progress
9. Action
  Change computer-system thresholds so early-order warnings appear one day before due dates and online ordering closes three days before due dates.
  Stated by North Laine Medical CentreStated completed
10. Action
  Add patients who overdose to the weekly prescription list.
  Stated by North Laine Medical CentreStated planned
11. Action
  Revise the practice prescribing policy using CCG pharmaceutical advice and discuss the updated policy in a whole-practice meeting.
  Stated by North Laine Medical CentreStated completed
12. Action
  Raise receptionist and GP awareness of patients ordering prescriptions too early, including when requested amounts appear small.
  Stated by North Laine Medical CentreStated completed
13. Action
  Review patients receiving controlled drugs and agree medication-reduction or cessation plans with them.
  Stated by North Laine Medical CentreStated in progress
14. Action
  Develop a computer-generated warning identifying patients with overdoses or suicide attempts when high-risk medicines are requested.
  Stated by North Laine Medical CentreStated in progress
15. Action
  Copy all GPs into reports of overdoses and other suicide attempts.
  Stated by North Laine Medical CentreStated completed
16. Action
  Code all overdoses and suicide attempts in the practice system.
  Stated by North Laine Medical CentreStated completed
AI-generated summary

Darren James CARRINGTON · 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

Darren James CARRINGTON died after collapsing with a fatal level of Zopiclone in his blood and did not recover. The inquest concluded that the death was misadventure, being an impulsive overdose while under the influence of alcohol. Concerns included the prescribing of potentially dependency-forming medication, excessive Zopiclone prescribing over 57 days, and the ability of receptionists and clinicians to override computer warnings and other safeguards.

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 apply adequate safeguards when prescribing potentially dependence-forming or misused medication
Wider context from the report
“The method of prescribing medication such as Zopiclone (in this case), Codeine, Morphine, Benzodiazepines etc. to patients which suggests that they either are or are very likely to be becoming dependent upon such medications or are misusing them. Examples of both the above would be too frequent requests for repeat prescriptions and information concerning a history of overdoses. The Inquest discussed whether circumstances, including those outlined above should trigger an automatic/mandatory medication review conducted with the patient; consideration of a different prescribing period and very careful monitoring of the online requests for repeat prescriptions. Alternatively, there could be a ban on the requests for repeat prescriptions with the repeats simply being issued for an appropriate period of time “automatically”. In this case as you will see from ████████ report, over twice the appropriate amount of Zopiclone was issued over a period of 57 days. The patient in question had Zopiclone present at a fatal level in his blood at the time of his collapse from which he never recovered. I remain very worried about these prescribing issues and about the fact that apparently receptionists and clinicians can override the warnings in the surgery’s computer system. I should like this to be carefully investigated and look forward to hearing with a response within the relevant time period. I realise that the situation may be exacerbated by GPs working part time and many part time practitioners being involved in the prescribing procedure as well as many receptionists being involved in it but if this is the trend then it seems to me the safeguards must be extended not made easier to override. The other ‘failsafe device’ is the dispensing pharmacist. When repeats are requested online there is a designated pharmacy. They receive emailed scripts. Their own systems should flag up cases of over or too frequent prescribing as well as other matters. ”
Source location
Darren James CARRINGTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Discuss discharge-information requirements with Emergency Department medical staff through regular governance meetings.

Verbatim wording from the response
“I am very sorry that Mr Carrington's GP, Sussex Partnership NHS Foundation Trust and Pavilions did not receive adequate information concerning the details of Mr Carrington’s mixed overdose and accept that this does not reflect good continuity of care. I can confirm that this has been fed back to ████████, Clinical Director for Emergency and Acute Medicine and to ████████, Consultant and Governance Lead for Emergency Medicine. ████████ have discussed these issues with all medical staff as part of the Emergency Department regular governance meetings to highlight the issues that arose from Mr Carrington’s attendances and the importance of ensuring that discharge letters contain sufficient detail.”

Source location
2018-0181-Response-from-Brighton-and-Sussex-University-Hospitals
Page 1 · response
Published 8 July 2018
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
Increase staff awareness of frequent requests for small medication quantities as potential risk indicators.

Verbatim wording from the response
“I can confirm that the following changes have been implemented at North Laine Surgery via a Practice Meeting attended by all staff:-”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Audit records of patients receiving Zopiclone and review their prescribed quantities.

Verbatim wording from the response
“I can confirm that the following changes have been implemented at North Laine Surgery via a Practice Meeting attended by all staff:-”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Review high-risk prescribing records and remove online prescription-request access for weekly, controlled, dependency-forming and potentially abusive medicines.

Verbatim wording from the response
“• Records of all patients receiving weekly prescriptions have been reviewed and access to on-line requests have been removed.”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Provide protected administrative and clinical staff time to manage prescription requests.

Verbatim wording from the response
“• Arrangements have been made to ensure administrative and clinical staff have adequate, protected time to manage prescription requests.”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Discuss sharing the high-risk medication review protocol with a linked practice.

Verbatim wording from the response
“• Ongoing discussions with linked Practice around sharing high risk medication review protocol.”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Lower computer-alert thresholds for early prescription ordering and increase awareness of relevant alerts.

Verbatim wording from the response
“• Computer settings changed with a view to lower thresholds for flagging up early ordering of scripts and increased awareness around the potential significance of these and other alerts.”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Embed the high-risk drug review protocol with support from the Medication Management team.

Verbatim wording from the response
“Our Medication Management team are providing ongoing support. In particular, around embedding The High Risk Drug review protocol mentioned above, as well as ensuring that the new Practice Repeat Prescribing Policy covers current best practice.”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Ensure the new Practice Repeat Prescribing Policy covers current best practice.

Verbatim wording from the response
“Our Medication Management team are providing ongoing support. In particular, around embedding The High Risk Drug review protocol mentioned above, as well as ensuring that the new Practice Repeat Prescribing Policy covers current best practice.”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Audit Zopiclone prescribing to verify repeat-template intervals, doses and limits, and reduce some prescription amounts.

Verbatim wording from the response
“2. An audit of all patients on Zopiclone was carried out to ensure that limits and doses were correctly entered on the system. There was no evidence that any other patients had over-ordered or done so too early.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Remove online prescription requests for controlled drugs and drugs of potential abuse or dependence, following patient assessment.

Verbatim wording from the response
“3. Access to online requests for controlled drugs has been removed for all patients. Following discussion with the patient and their doctor, this may be restored if the patient is considered “low-risk”.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Change computer-system thresholds so early-order warnings appear one day before due dates and online ordering closes three days before due dates.

Verbatim wording from the response
“4. An investigation into online ordering and script generation by the computer system was conducted in conjunction with the practice IT co-ordinator. As a result, the timings were changed within the system so that warnings about scripts being ordered too early were changed from 7 to 1 day and ordering online from 10 to 3 days.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Add patients who overdose to the weekly prescription list.

Verbatim wording from the response
“5. Patients who overdose will be added to the weekly script list.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Revise the practice prescribing policy using CCG pharmaceutical advice and discuss the updated policy in a whole-practice meeting.

Verbatim wording from the response
“6. There has been an extensive revision of the practice prescribing policy incorporating suggestions from the CCG pharmaceutical adviser and we are having a practice meeting on 24th July to discuss further. We look forward to working with her again over the next year to improve further our systems.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Raise receptionist and GP awareness of patients ordering prescriptions too early, including when requested amounts appear small.

Verbatim wording from the response
“7. There has been a raised awareness of the potential of any patient to over-order medication, whether by accident or design.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Review patients receiving controlled drugs and agree medication-reduction or cessation plans with them.

Verbatim wording from the response
“9. A whole practice meeting took place on 24th July to discuss the updated practice prescribing policy. Ongoing review of patients on controlled drugs ████████ ████████ will occur and a plan to reduce and/or stop agreed with the patient. This will complement what the practice already has put in place over the past 2 years in terms of reduction programmes for patients.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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 a computer-generated warning identifying patients with overdoses or suicide attempts when high-risk medicines are requested.

Verbatim wording from the response
“10. A further meeting is planned with the practice IT coordinator to highlight automatically patients who have taken an overdose when certain high-risk drugs are requested. We hope to have this in place shortly.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Copy all GPs into reports of overdoses and other suicide attempts.

Verbatim wording from the response
“Action plan following meeting held on 22nd May which have been implemented by the practice.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 3 · response
Published 8 July 2018
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
Code all overdoses and suicide attempts in the practice system.

Verbatim wording from the response
“Action plan following meeting held on 22nd May which have been implemented by the practice.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 3 · response
Published 8 July 2018
Open published response
1 Apr2018
South London
Concerns raised1
1. Failure to follow NICE guidelines for prescribing off-licence medicines
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Send all doctors relevant guidance on prescribing off-license medicines and require them to follow it in practice.
  Stated by Oxleas NHS Foundation TrustStated planned
2. Action
  Hold an educational meeting before the end of summer to reinforce off-license prescribing guidance and its application.
  Stated by Oxleas NHS Foundation TrustStated planned
3. Action
  Require doctors to include off-license prescribing practice in appraisals and reflect on its effect on their practice.
  Stated by Oxleas NHS Foundation TrustStated planned
1. Action
  Require ward pharmacists to review off-license medication processes, including discussions, capacity, efficacy, risks and benefits, and share concerns with prescribers and Clinical Directors.
  Stated by Oxleas NHS Foundation TrustStated planned
2. Action
  Conducted a follow-up inspection of Oxleas NHS Foundation Trust’s acute wards to assess whether specific improvements had been made.
  Stated by Care Quality CommissionStated completed
3. Action
  Return to inspect Oxleas NHS Foundation Trust and follow up the identified concerns to check that necessary improvements have been made.
  Stated by Care Quality CommissionStated planned
Respondent positions 2
1. Position
  Specific circumstances of Julia MacPherson’s individual care and treatment fall outside the regulator’s remit for comment.
  Stated by Care Quality CommissionOutside remit
1. Position
  The inspection concluded that prescribing followed NICE guidance and raised no concerns about managing medicines prescribed outside usual levels.
  Stated by Care Quality CommissionDisputes the concern
AI-generated summary

Julia Jane MacPherson · 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

Julia Jane MacPherson, an informal patient of Oxleas NHS Foundation Trust, suffered swallowing difficulties and collapsed in the community with food bolus and vomitus in her throat; resuscitation was unsuccessful. Concerns included failure to arrange or undertake a timely medical review, failure to assess her mental capacity after concerns about confusion, incomplete clinical records, and prescribing and consent processes for off-licence medication. The inquest recorded the medical cause of death as upper airway obstruction associated with swallowing difficulties secondary to medication-related extrapyramidal symptoms.

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 follow NICE guidelines for prescribing off-licence medicines
Wider context from the report
“(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients. ”
Source location
Julia Jane MacPherson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Send all doctors relevant guidance on prescribing off-license medicines and require them to follow it in practice.

Verbatim wording from the response
“Although NICE does not issue specific guidance for the use of off licence medications, the General Medical Council and various Royal Colleges including the Royal College of Psychiatrists have issued advice for doctors when prescribing outside of license. A letter with the respective guidance will be sent to all doctors reminding them that they must follow these in practice. In addition, an educational meeting will take place before the end of summer to remind doctors of the guidance and ensure that it is being followed in practice. Trust doctors (consultant and non-consultant grade) are expected to include this in their appraisals and reflect on how this has changed their practice.”

Source location
2018-0298-Oxleas-NHS-Foundation-Trust
Page 2 · response
Published 19 January 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Hold an educational meeting before the end of summer to reinforce off-license prescribing guidance and its application.

Verbatim wording from the response
“Although NICE does not issue specific guidance for the use of off licence medications, the General Medical Council and various Royal Colleges including the Royal College of Psychiatrists have issued advice for doctors when prescribing outside of license. A letter with the respective guidance will be sent to all doctors reminding them that they must follow these in practice. In addition, an educational meeting will take place before the end of summer to remind doctors of the guidance and ensure that it is being followed in practice. Trust doctors (consultant and non-consultant grade) are expected to include this in their appraisals and reflect on how this has changed their practice.”

Source location
2018-0298-Oxleas-NHS-Foundation-Trust
Page 2 · response
Published 19 January 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Require doctors to include off-license prescribing practice in appraisals and reflect on its effect on their practice.

Verbatim wording from the response
“Although NICE does not issue specific guidance for the use of off licence medications, the General Medical Council and various Royal Colleges including the Royal College of Psychiatrists have issued advice for doctors when prescribing outside of license. A letter with the respective guidance will be sent to all doctors reminding them that they must follow these in practice. In addition, an educational meeting will take place before the end of summer to remind doctors of the guidance and ensure that it is being followed in practice. Trust doctors (consultant and non-consultant grade) are expected to include this in their appraisals and reflect on how this has changed their practice.”

Source location
2018-0298-Oxleas-NHS-Foundation-Trust
Page 2 · response
Published 19 January 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Require ward pharmacists to review off-license medication processes, including discussions, capacity, efficacy, risks and benefits, and share concerns with prescribers and Clinical Directors.

Verbatim wording from the response
“The Trust will make clear its expectations of all doctors to regularly assess and document capacity and consent to treatment for informal patients. This should be done as part of the weekly MDT review process and where there are concerns about a patient’s capacity to understand the treatment then the patient’s informal status must be reviewed and detention sought. This will ensure that such patients come under the statutory process described above. For patients prescribed off-license medication, the ward pharmacist will review the medications and ensure that all processes: discussion with patient and relatives, on-going capacity assessments and efficacy of treatment and risk/ benefits have been checked and are documented. If there are any concerns these will be shared with the consultant prescribing the medication and their Clinical Director.”

Source location
2018-0298-Oxleas-NHS-Foundation-Trust
Page 2 · response
Published 19 January 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conducted a follow-up inspection of Oxleas NHS Foundation Trust’s acute wards to assess whether specific improvements had been made.

Verbatim wording from the response
“Since Julia Jane MacPherson's death in May 2016, we have inspected Oxleas NHS Foundation Trust once. This was a follow up inspection of the acute wards in the Trust, including Norman Ward, in February 2017 to see if some specific improvements had taken place since the comprehensive inspection in April 2016. We also carried out regular visits by our Mental Health Act reviewers, and the last one took place on Norman Ward in March 2017.”

Source location
2018-0298-Response-by-CQC
Page 1 · response
Published 19 January 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Return to inspect Oxleas NHS Foundation Trust and follow up the identified concerns to check that necessary improvements have been made.

Verbatim wording from the response
“We will be returning to inspect Oxleas NHS Foundation Trust later in the year. We intend to follow through some of the areas of concern in more detail. This will be to ensure the trust has learnt from this and made the necessary improvements.”

Source location
2018-0298-Response-by-CQC
Page 2 · response
Published 19 January 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Specific circumstances of Julia MacPherson’s individual care and treatment fall outside the regulator’s remit for comment.

Verbatim wording from the response
“We note our legal responsibility to submit a written response to you, however some of the matters of concern relate to the very specific circumstances of Julia MacPherson's individual care and treatment, so we are unable as a regulator to comment on this.”

Source location
2018-0298-Response-by-CQC
Page 1 · response
Published 19 January 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The inspection concluded that prescribing followed NICE guidance and raised no concerns about managing medicines prescribed outside usual levels.

Verbatim wording from the response
“The inspection in April 2016 looked at 105 medicine administration records and concluded that NICE guidance was being followed when prescribing medicines. We did record that three patients were being prescribed medicines outside of the usual levels, but do not raise any concerns about how that was being managed.”

Source location
2018-0298-Response-by-CQC
Page 2 · response
Published 19 January 2019
Open published response
27 Feb2018
Suffolk
Concerns raised1
1. Failure to prescribe safe quantities of discharge medication for patients at risk of stockpiling medication
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Assess medications prescribed on discharge across the Trust.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated in progress
AI-generated summary

Rachel Holly Edwards · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Rachel Holly Edwards died on 8 May 2017 after an overdose of multiple prescription medicines, following a period of severe and unbearable pain. Concerns identified at the inquest included unclear quantities of discharge medication, inadequate communication of prescriptions to her GP, record-keeping weaknesses, and the absence of a formal patient advocate system to support her when pain-management news and treatment administration increased her hopelessness.

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 safe quantities of discharge medication for patients at risk of stockpiling medication
Wider context from the report
“The first concern regards the prescription of discharge medication, sharing that information with the GP and record keeping. It was known that Rachel was at risk of stockpiling medication as in the Serious Incident Requiring Investigation (SIRI) report it is noted that a request made on the 7th March 2017 by her treating doctor, for the disposal of her stocks of medication had not been actioned. Further, Rachel's care co-ordinator specifically recalled asking Rachel if she had stockpiled any medication after her discharge on the 29th March 2017, as he had identified this to be a risk. It is therefore a concern that according to Rachel's notes that on the day of her discharge she was supplied with 14 days of medication. This was described in evidence as ‘standard practice’. That said, some consideration appears to have been given to the quantity of some medication issued, as on closer inspection of the notes it was identified that specifically in relation to Tramadol Rachel had been prescribed this for only a 7-day period. However, there was no clear record within the notes if her other medication had actually been issued in 7 or 14 days amounts. Such confusion over the actual quantities of medication issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a view to self-harm, is of obvious concern. Also of concern was evidence given by a senior consultant that there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands. Obviously, it is crucial that this information is readily available to a GP in all cases, to ensure that the over-prescription of medicines to a recently discharged patient does not occur. Evidence was heard that in order for Woodlands to notify a GP it is necessary for a staff member to e-mail the relevant practice, providing details of the prescriptions that had been made. This information would then have to be subsequently included in the patient's local record before it was available to the treating GP. Obviously, any system requiring such physical human input can be prone to failure and in the consultant's own words it was a recognised ‘point of weakness in the system’. ”
Source location
Rachel Holly Edwards · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Assess medications prescribed on discharge across the Trust.

Verbatim wording from the response
“The Trust will make an assessment of the medications prescribed upon discharge and this consideration will continue across the Trust. In the majority of situations an individual’s recovery into the community is supported by a period of care with the Crisis Resolution and Home Treatment team.”

Source location
Response from Norfolk and Suffolk NHS Foundation Trust
Page 1 · response
Published 30 April 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Medication prescribing errors involving incorrect doses

Inappropriate prescribing of large medication quantities during an initial medication switch

Concerns raised2

Failure to access the patient’s medical records before prescribing potentially dangerous and addictive drugs

Failure to contact the patient’s regular medical practitioner before prescribing potentially dangerous and addictive drugs

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

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

Concerns raised1

Failure to follow senior clinician anticoagulant-duration advice

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

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

Concerns raised1

Lack of guidance for clinicians on prescribing highly addictive and potentially harmful drugs alongside one another

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised3

Failure to check the medicines database before prescribing duplicate medication doses

Failure to prevent inappropriate continuing prescriptions of Fondaparinux and Ticagrelor

Failure to prescribe aspirin at the standard continuing dose

Concerns raised1

Potentially unsafe clomipramine prescribing practices

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to accurately transcribe intended steroid doses when rewriting drug charts

Concerns raised1

Failure to apply adequate safeguards when prescribing potentially dependence-forming or misused medication

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.19

Actions described in response 1

Respondent positions 2

Actions described in response 1

Respondent positions 2

Actions described in response 1

Respondent positions 1

Actions described in response 19