16 Oct 2024 Paul Michael Clark · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to consider the risks of prescribing opioids to patients with former opioid addiction View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS Greater Manchester Integrated Care Board Royal College of General Practitioners
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS Greater Manchester Integrated Care Board
Deliver opioid-prescribing masterclass training to Stockport GPs and clinicians.
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NHS Greater Manchester Integrated Care Board
Create, disseminate and use a seven-minute briefing based on learning from the Regulation 28 report.
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Royal College of General Practitioners
Publish and maintain continuing professional development updates on opioid use disorder, medicine dependence, withdrawal symptoms and opioid reduction.
View source
Royal College of General Practitioners
Develop, launch and widely circulate a repeat-prescribing toolkit supporting safer, collaborative prescribing processes and addressing opioid-prescribing safety concerns.
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AI-generated summary
Paul Michael Clark · 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
Paul Michael Clark was found unresponsive at home on 12 May 2024 and died from drug toxicity; the inquest concluded that the death was accidental. The principal concern was that opioid painkillers were prescribed despite his documented previous heroin addiction, without evidence that the risks of reintroducing opioids were considered or monitored, and he subsequently became addicted and took increasing amounts, including non-prescribed opioids.
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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 consider the risks of prescribing opioids to patients with former opioid addiction
Wider context from the report “The inquest heard evidence that Paul Clark had previously been addicted to heroin. He had been successful in treating his opioid addiction and had remained opioid free for many years. His previous problems with opioids and the risks of opioids for him were well documented within his medical notes. However despite the risks opioid painkillers presented to him he had been started in primary care on opioid based painkillers for reported pain. He had become addicted to them and took them at increasing levels topping them up with non-prescribed opioids. There was no evidence before the inquest that the inherent risks of reintroducing opioids to someone who had previously been addicted to them were considered or monitored. It was accepted in evidence that whilst opioid painkillers can be helpful for treating some patients the risks of treating a patient with a former opioid addiction with opioids were significant and that there needed to be a very well thought out rationale with careful monitoring to avoid increasing the chances of a patient relapsing into addiction through GP prescribed medication and that it was essential that GPs considered this when prescribing .
” Source location Paul Michael Clark · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver opioid-prescribing masterclass training to Stockport GPs and clinicians.
Verbatim wording from the response “In order to support our wider GP population, a Masterclass presentation on the subject of opioid prescribing was delivered to Stockport GPs and clinicians on 12 September 2024. The session title was ‘Pain Transformation, IMPS and Opioid Stewardship’. A total of 62 clinicians attended the session which was delivered by Dr Thomas Walton, Consultant in Anaesthesia and Pain Management.” Source location Response from GMIC
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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 Create, disseminate and use a seven-minute briefing based on learning from the Regulation 28 report.
Verbatim wording from the response “The Regulation 28 report and our response will also be shared, in January 2025, for system learning with the GM cross-sector medicines safety group - the IPMO Medicines Safety Group. This group reports to the Greater Manchester Medicines Management Group (GMMG) and is co-chaired by NHS GM and Manchester University NHS Foundation Trust (MFT). The intention is to reflect on any learning from the Regulation 28 report and create a 7-minute briefing to be produced, disseminated to clinical staff and used for shared learning.” Source location Response from GMIC
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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 Publish and maintain continuing professional development updates on opioid use disorder, medicine dependence, withdrawal symptoms and opioid reduction.
Verbatim wording from the response “Continuing Professional Development” Source location Response from RCGP
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 Develop, launch and widely circulate a repeat-prescribing toolkit supporting safer, collaborative prescribing processes and addressing opioid-prescribing safety concerns.
Verbatim wording from the response “Clinical Policy” Source location Response from RCGP
Open published response
9 Sep 2024 Amanda Richardson · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure of hospital systems to review and safeguard medication prescribing and administration View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Amanda Richardson · 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
Amanda Richardson, aged 40, was transferred from prison to a low secure mental health hospital and was found dead in her bedroom on 29 April 2023. Toxicology found a very high level of a prescribed drug, which had been prescribed at double the stipulated maximum dose, alongside evidence of illicit drug use. The concerns included inadequate medication review and monitoring, failures to record and investigate searches, and the adequacy of hospital security arrangements.
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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 of hospital systems to review and safeguard medication prescribing and administration
Wider context from the report “2. It was admitted that the prescription of ████████ at the rate of ████████mg/day was double the ████████mg/day stipulated maximum (without additional monitoring being undertaken) and was made in error. This situation went unnoticed for some six months, until her death. There was no effective system of review in the hospital in this period. The pharmacist appears to have dispensed the drug without querying the high dose. The nurses who administered the drugs did not question it. The MDT meetings which took place did not check the dose, or reflect upon its potential interaction with the several other medications prescribed. Overall, there was no effective resilience in the hospital’s systems to safeguard against drugs bring prescribed or administered in error .
” Source location Amanda Richardson · Prevention of Future Deaths report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Actions taken following the Serious Incident Report are considered sufficient to address identified issues and prevent similar future deaths.
Verbatim wording from the response “Inmind Healthcare remain committed to learning and improving service but given the assurances given to the Coroner at the Inquest, Inmind Healthcare consider that actions have been taken to fully address the issues identified by the Serious Incident Report and to prevent future deaths in similar circumstances.” Source location Response from InMind
Open published response
Concerns raised 1
Inconsistent units in local anaesthetic prescribing View source
This report raised 7 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
Rachel Gibson · 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 Gibson underwent hip replacement surgery in April 2022 and received an excessive dose of Ropivacaine, after which she suffered an unwitnessed cardiac arrest and irreversible brain damage. She died in hospital on 14 July 2022. The principal concerns were unclear responsibilities for prescribing, checking and administering the local anaesthetic, inconsistent prescription units, and wide variation in similar practices nationally.
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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 Inconsistent units in local anaesthetic prescribing
Wider context from the report “1. The responsibility for checking and administering the local anaesthetic is unclear:
1. The instruction was given orally and not written down by the anaesthetist (the prescriber).
2. The anaesthetist did not check what the nurse had written down.
3. The nurse drew up the local anaesthetic from a stock bag and checked this with another nurse, but not with the anaesthetist.
4. The nurse then handed the drawn-up anaesthetic to the surgeon to administer.
2. There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced.
3. The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation. However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation. This is why I believe I am under a duty to draw it to your attention.
” Source location Rachel Gibson · Prevention of Future Deaths report
Open source report
16 Jul 2024 Jessica de Souza · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure to ensure aripiprazole monotherapy is effective for prophylaxis against both bipolar polarities View source
Linked responses
BMJ Publishing Group Limited (BMJ Group BNF Publications National Institute for Health and Care Excellence
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
National Institute for Health and Care Excellence
Discuss long-term bipolar disorder treatment across both polarities with NICE topic experts.
View source
National Institute for Health and Care Excellence
Review new evidence that could affect NICE’s long-term bipolar disorder treatment recommendations.
View source
BNF Publications
Monitor emerging bipolar-disorder management information and consider adding appropriate detail in a future BNF update.
View source
BMJ Publishing Group Limited (BMJ Group
Update the bipolar disorder topic to discuss guideline differences and incorporate the NICE guideline in greater detail.
View source
BMJ Publishing Group Limited (BMJ Group
Continue reviewing and updating the bipolar disorder topic with subject matter experts and incorporating new evidence as appropriate.
View source See 2 more actions
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AI-generated summary
Jessica de Souza · 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
Jessica de Souza, who had bipolar disorder, developed depression after a family bereavement and took her own life by hanging at home on 1 February 2023. Concerns included that aripiprazole was prescribed as monotherapy for both polarities of bipolar disorder, although expert evidence stated it was not effective prophylaxis against depressive relapse. The expert also considered that the guidance relied on by clinicians may have been misleading.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure aripiprazole monotherapy is effective for prophylaxis against both bipolar polarities
Wider context from the report “i. The treating psychiatrists gave evidence that, following the acute manic episode, Jessica was prescribed aripiprazole as a maintenance prophylactic drug to control both polarities of bipolar disorder.
ii. The clinicians relied on the BNF and the BMJ Best Practice Bipolar Disorder in Adults to support their decision to prescribe aripiprazole as prophylaxis for both polarities as a monotherapy.
iii. Nice Guidance on Bipolar Disorder [CG185] suggests aripiprazole may be considered as a maintenance treatment to prevent relapse in bipolar disorder.
iv. The BMJ refers to aripiprazole being used as a monotherapy to treat bipolar disorder, though does advise that it is more effective in preventing mania than depression.
v. The court appointed psychiatric expert gave evidence that aripiprazole is not effective as a prophylaxis in relation to the depressive polarity in bipolar and that as a result Jessica was not protected from a depressive relapse.
vi. The expert considered that the guidance relied on may have been misleading for the clinicians.
” Source location Jessica de Souza · 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 Discuss long-term bipolar disorder treatment across both polarities with NICE topic experts.
Verbatim wording from the response “Our senior clinical advisers acknowledge that the guideline does not explicitly consider the 2 polarities of bipolar disorder in long-term treatment. We will discuss this area with our topic experts and review any new evidence that could impact on our recommendations, updating them if necessary.” Source location Response from NICE
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 Review new evidence that could affect NICE’s long-term bipolar disorder treatment recommendations.
Verbatim wording from the response “Our senior clinical advisers acknowledge that the guideline does not explicitly consider the 2 polarities of bipolar disorder in long-term treatment. We will discuss this area with our topic experts and review any new evidence that could impact on our recommendations, updating them if necessary.” Source location Response from NICE
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 Monitor emerging bipolar-disorder management information and consider adding appropriate detail in a future BNF update.
Verbatim wording from the response “As we do for all BNF content, we will continue to monitor for additional sources of information around the management of bipolar disorder, and consider whether we need to include further” Source location Response from Royal Pharmaceutical Society
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 Update the bipolar disorder topic to discuss guideline differences and incorporate the NICE guideline in greater detail.
Verbatim wording from the response “In updates since 2022, the topic discusses in more detail the differences between guidelines, and incorporates the NICE guideline in greater detail but there has been no substantive change to the content that is relevant to the report. In keeping with our processes, we will continue to review and update this topic with subject matter experts and will incorporate new evidence into the content as appropriate.” Source location Response from BMJ Group
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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 Continue reviewing and updating the bipolar disorder topic with subject matter experts and incorporating new evidence as appropriate.
Verbatim wording from the response “In updates since 2022, the topic discusses in more detail the differences between guidelines, and incorporates the NICE guideline in greater detail but there has been no substantive change to the content that is relevant to the report. In keeping with our processes, we will continue to review and update this topic with subject matter experts and will incorporate new evidence into the content as appropriate.” Source location Response from BMJ Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The content of the BNF and BMJ Best Practice is outside NICE’s responsibility, so NICE cannot comment on it.
Verbatim wording from the response “The BNF is a joint publication of the British Medical Association and the Royal Pharmaceutical Society. NICE hold the licence to make this resource available on the NICE website to health professionals working in the UK, but we are not responsible for the content.” Source location Response from NICE
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The BNF and BMJ Best Practice publishers are best placed to respond to concerns about their content.
Verbatim wording from the response “I note that you have sent your report to those parties, and they are best placed to respond to your comments on their content.” Source location Response from NICE
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The BNF guidance was not misleading because it did not recommend aripiprazole for prophylaxis of bipolar depression and advised specialist input.
Verbatim wording from the response “The matter of concern that directly references the BNF states that the clinicians relied on the BNF (and the BMJ Best Practice Bipolar Disorder in Adults) to support their decision to prescribe aripiprazole as prophylaxis for both polarities as a monotherapy. In Summer 2022, when aripiprazole was first prescribed to Ms De Souza, the aripiprazole drug monograph in BNF included one indication that was relevant to the management of bipolar disorder – that is the treatment and recurrence prevention of mania. The indication reflected, and continues to reflect, the licensed use of oral aripiprazole in licensed product information and is unchanged in current BNF content. The BNF does not include information on the use of aripiprazole as prophylaxis for bipolar depression.” Source location Response from Royal Pharmaceutical Society
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Selection and management of bipolar treatment remain the treating clinicians’ responsibility because they know the patient’s full clinical context.
Verbatim wording from the response “The BMJ Best Practice ‘Bipolar Disorder in Adults’ topic, at the time (and still does) discusses the complex nature of bipolar disorder and the many factors to consider and monitor during treatment. It outlines the different phases in terms of acute mania, acute depression and patients with mixed features, as well as maintenance treatment, and the differing treatment options and considerations during each phase. It is the duty of the treating doctor to take all of this into account when deciding on treatments.” Source location Response from BMJ Group
Open published response
Concerns raised 1
Failure of doctors to obtain all relevant patient information before prescribing warfarin View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals of Leicester 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
University Hospitals of Leicester NHS Trust
Continue developing the electronic patient record to make patients’ available clinical information accessible in one system.
View source
University Hospitals of Leicester NHS Trust
Deploy electronic clinical notation in the emergency department.
View source
University Hospitals of Leicester NHS Trust
Incorporate warfarin prescribing into the digital system to provide clinicians with more patient information.
View source
University Hospitals of Leicester NHS Trust
Embed a digital reminder requiring MDT colleagues to record pertinent clinical information and patient-condition changes in digital warfarin dosage requests.
View source See 1 more action
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AI-generated summary
John Kenneth PARRY · 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
John Parry, aged 72, was admitted to Leicester Royal Infirmary on 4 July 2023 after feeling unwell and later suffered two unwitnessed falls. He died on 7 July 2023 after a spontaneous intracerebral bleed was diagnosed. The inquest raised concerns that neurological observations after the falls were not carried out in accordance with hospital policy, the calculations were inaccurate, and a CT head scan that should have occurred within one hour was not performed. A separate concern concerned communication and information-sharing when prescribing warfarin.
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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 of doctors to obtain all relevant patient information before prescribing warfarin
Wider context from the report “The evidence heard raised a concern about the safe prescribing of warfarin. When a doctor is asked by a nurse to dose the warfarin, the accepted practice is that the doctor relies on the nurse to give all relevant information and the doctor only checks the INR blood results from the laboratory . There is no requirement or expectation that the doctor looks at the patient’s medical records or seeks information about the patient . At the inquest evidence was heard that the nurse had not communicated all relevant information. Although in this case it did not have an adverse outcome, it was accepted that there was a risk that if a doctor does not have all relevant information, warfarin could be prescribed and administered and there could be a risk of death . Evidence was given that this lack of appropriate communication was believed to be unusual but it was accepted that it is not necessarily known how unusual because it would probably only become apparent in cases of an adverse outcome.
” Source location John Kenneth PARRY · 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 Continue developing the electronic patient record to make patients’ available clinical information accessible in one system.
Verbatim wording from the response “We are also developing our electronic patient record system to enable clinicians to review all available information about a patient on one system. Earlier this year we successfully deployed electronic clinical notation in our emergency department and aim to roll this across our inpatient areas pending additional developments of the system with the vendor. In addition, we have now incorporated warfarin prescribing into our digital system allowing clinicians access to more information about the patient without having to log-in to another system. As we further roll out electronic notation, clinicians will increasingly be able to access more information about the patient in one system.” Source location Response from University Hospitals Leicester
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 Deploy electronic clinical notation in the emergency department.
Verbatim wording from the response “We are also developing our electronic patient record system to enable clinicians to review all available information about a patient on one system. Earlier this year we successfully deployed electronic clinical notation in our emergency department and aim to roll this across our inpatient areas pending additional developments of the system with the vendor. In addition, we have now incorporated warfarin prescribing into our digital system allowing clinicians access to more information about the patient without having to log-in to another system. As we further roll out electronic notation, clinicians will increasingly be able to access more information about the patient in one system.” Source location Response from University Hospitals Leicester
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 Incorporate warfarin prescribing into the digital system to provide clinicians with more patient information.
Verbatim wording from the response “We are also developing our electronic patient record system to enable clinicians to review all available information about a patient on one system. Earlier this year we successfully deployed electronic clinical notation in our emergency department and aim to roll this across our inpatient areas pending additional developments of the system with the vendor. In addition, we have now incorporated warfarin prescribing into our digital system allowing clinicians access to more information about the patient without having to log-in to another system. As we further roll out electronic notation, clinicians will increasingly be able to access more information about the patient in one system.” Source location Response from University Hospitals Leicester
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 Embed a digital reminder requiring MDT colleagues to record pertinent clinical information and patient-condition changes in digital warfarin dosage requests.
Verbatim wording from the response “To help improve communication further, we will embed a digital reminder for all MDT colleagues to include pertinent clinical information or any changes to the patient’s condition when generating a digital warfarin dosage request for the patient. Due to a need to ensure appropriate testing and governance, these changes will take time to fully implement across the whole of UHL, but we anticipate this will occur by December 2025. Our eHospital team, which is chaired by our Medical Director will oversee these changes.” Source location Response from University Hospitals Leicester
Open published response
21 May 2024 Tracy Frances MCCARTHY · Prevention of Future Deaths report Inner North London
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Concerns raised 3
Prescribing of amitriptyline above the maximum suggested dose for a patient known to be dependent on it View source Failure to flag the overdose risk and stop continued amitriptyline prescribing View source Prescribing of amitriptyline for depression despite its increased risk of fatality in overdose View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Tredegar Practice
Identify eligible complex patients, add them to the Risk Management & Care Planning Register, and create corresponding care plans and EMIS alerts.
View source
Tredegar Practice
Conduct regular reviews of registered patients and the overall framework, documenting, minuting, and circulating review outcomes.
View source
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AI-generated summary
Tracy Frances MCCARTHY · 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
Tracy McCarthy was found deceased at home on 17 July 2023 and died from long-term misuse of amitriptyline; the inquest conclusion was a drug-related death, with amitriptyline toxicity and coronary artery disease recorded. The concerns included prescribing amitriptyline above the maximum suggested dose, failure to flag the overdose risk and stop or appropriately manage the prescription, and changing from daily to monthly prescriptions despite recognised risks.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Prescribing of amitriptyline above the maximum suggested dose for a patient known to be dependent on it
Wider context from the report “(1) Although Amitriptyline is not generally regarded as a drug of abuse, Ms McCarthy was known to be dependent on it . She had been prescribed Amitriptyline for many years, and at one stage in or about 2022, she was regularly prescribed ████████ mg per day, which is over the maximum suggested dose in the BNF (150mg per day) . In addition, the BNF provides a clear warning (as did the prescribing/records software in use at The Tredegar Practice) that Amitriptyline prescribed for depression (which it was in this case), is “not recommended – increased risk of fatality in overdose”. A GP from The Tredegar Practice told me that ████████ mg was an “unacceptable dose” .
The concern being that guidelines were not followed, particularly in relation to a patient known to be dependent and where use of Amitriptyline was not recommended for the presenting condition in any event.
” Source location Tracy Frances MCCARTHY · 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 flag the overdose risk and stop continued amitriptyline prescribing
Wider context from the report “(2) Following Ms McCarthy’s admission to hospital as a result of an overdose of Amitriptyline and Codeine, The Tredegar Practice received information from the hospital, making reference to the overdose. Despite this, the risk was not flagged and no alert was put on the system ; as such, the prescription of Amitriptyline continued . A GP from The Tredegar Practice told me, “[the Amitriptyline] should have been stopped, but knowing [the patient] that would have been very hard to do.”
” Source location Tracy Frances MCCARTHY · 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 Prescribing of amitriptyline for depression despite its increased risk of fatality in overdose
Wider context from the report “(1) Although Amitriptyline is not generally regarded as a drug of abuse, Ms McCarthy was known to be dependent on it. She had been prescribed Amitriptyline for many years, and at one stage in or about 2022, she was regularly prescribed ████████ mg per day, which is over the maximum suggested dose in the BNF (150mg per day). In addition, the BNF provides a clear warning (as did the prescribing/records software in use at The Tredegar Practice) that Amitriptyline prescribed for depression (which it was in this case), is “not recommended – increased risk of fatality in overdose” . A GP from The Tredegar Practice told me that ████████ mg was an “unacceptable dose”.
The concern being that guidelines were not followed, particularly in relation to a patient known to be dependent and where use of Amitriptyline was not recommended for the presenting condition in any event .
” Source location Tracy Frances MCCARTHY · 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 Identify eligible complex patients, add them to the Risk Management & Care Planning Register, and create corresponding care plans and EMIS alerts.
Verbatim wording from the response “2. Identification of patients to be entered into the framework.” Source location Response from The GP Partners
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 Conduct regular reviews of registered patients and the overall framework, documenting, minuting, and circulating review outcomes.
Verbatim wording from the response “4. Reviews: regular reviews will be needed in the process.” Source location Response from The GP Partners
Open published response
8 Apr 2024 Joshua Arthur Stafford Delaney · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1
Failure to limit quantities of Propranolol prescribed to people at risk of overdose 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
Joshua Arthur Stafford Delaney · 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
Joshua Arthur Stafford Delaney, aged 19, had a history of mental illness, suicidal ideation and previous suicide attempts. On 19 January 2020, he took a large overdose of Propranolol, was found collapsed, and died despite resuscitation attempts. The principal concern was that GPs may not be aware of the risk of fatal Propranolol overdose and may prescribe quantities to people at risk, potentially causing future deaths.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to limit quantities of Propranolol prescribed to people at risk of overdose
Wider context from the report “The evidence of the General Practitioner in this case was to the effect that prior to this death, neither he nor his colleagues were aware that Propranolol carried any significant risk of death through deliberate overdose. The evidence of the doctor in question was that because of this specific incident, there has been a change in their approach to prescribing of Propranolol at his GP surgery, with smaller quantities prescribed (1 to 10 patients who might be at risk of taking an overdose. Shortly after this incident (11 February 2020) there was, coincidentally, an article in the British Medical Journal in respect of Propranolol, ("Doctors and paramedics must be better prepared to deal with propranolol overdoses"). However, the doctor’s evidence in the inquest was that he did not believe that GPs generally were currently aware of the risk of Propranolol overdoses.
The evidence from the Consultant Psychiatrist from the Community Mental Health Team was that they would not usually prescribe Propranolol, and he also considered that GPs may not be aware of the overdose risk posed by the drug.
The inquest also heard from the toxicologist, who gave evidence that her anecdotal experience was that there had in recent years been a significant number of deaths caused by Propranolol overdoses.
In the circumstances, I am concerned that doctors in General Practice may not be aware of the risks of fatal overdose from Propranolol, and that in the absence of greater awareness by GPs, the prescription of quantities of Propranolol to those at risk may cause future deaths .
” Source location Joshua Arthur Stafford Delaney · Prevention of Future Deaths report
Open source report
4 Mar 2024 Mr Lee Martin Hughes, also known as Martin Lee Hughes · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3
Insufficient specialist expertise in prescribing drug treatments for withdrawal View source Failure to withhold or reduce methadone when patients show signs of sedation View source Failure to account for reduced opiate tolerance and synergistic agents when prescribing methadone View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England Oxleas NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Oxleas NHS Foundation Trust
Require acute withdrawal prescribers to complete recognised specialist substance-misuse training to at least RCGP part-one level.
View source
Oxleas NHS Foundation Trust
Employ a full-time substance-misuse practitioner to oversee five-day reviews, quality assurance, audit, supervision and team development.
View source
NHS England
Update the national service specification using learning from the case to strengthen prescribing and supply of sedating medicines.
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Oxleas NHS Foundation Trust
Revise and disseminate the withdrawal-treatment policy, including sedation safeguards, tolerance assessment, urine screening and clinical review requirements.
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Oxleas NHS Foundation Trust
Discuss the case in a prescriber reflective-practice forum, focusing on individual history, clinical signs, investigations and cautious methadone dosing.
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AI-generated summary
Mr Lee Martin Hughes, also known as Martin Lee Hughes · 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
Lee Martin Hughes was found deceased in his cell at HMP Wandsworth on 25 December 2021 while remanded in custody. The medical cause of death was methadone and benzodiazepine intoxication, and the jury concluded that drug-related misadventure was contributed to by neglect. Concerns included the assessment and prescribing of methadone, failure to respond appropriately to signs of sedation and impaired consciousness, and inadequate communication and escalation between healthcare disciplines.
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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 Insufficient specialist expertise in prescribing drug treatments for withdrawal
Wider context from the report “2. That prescribing of drug treatments for withdrawal should only be undertaken by substance misuse practitioners , who should therefore be more experienced as to when, whether and how much to prescribe .
” Source location Mr Lee Martin Hughes, also known as Martin Lee Hughes · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to withhold or reduce methadone when patients show signs of sedation
Wider context from the report “5. That methadone should be withheld and or reduced if the patient/inmate is showing signs of sedation .
” Source location Mr Lee Martin Hughes, also known as Martin Lee Hughes · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to account for reduced opiate tolerance and synergistic agents when prescribing methadone
Wider context from the report “4. That practitioners when prescribing consider whether time spent in custody prior to remand may have reduced an individual's tolerance to opiates , especially when methadone is to be prescribed with a synergistic agent such as a benzodiazepine .
” Source location Mr Lee Martin Hughes, also known as Martin Lee Hughes · 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 acute withdrawal prescribers to complete recognised specialist substance-misuse training to at least RCGP part-one level.
Verbatim wording from the response “2. The policy for the pharmacological treatment of drugs and alcohol withdrawal within the early days in custody has been reviewed, substantially revised and disseminated by the medicines management committee, with input from specialist substance misuse practitioners. It is a requirement that all prescribers of acute withdrawal medications at HMP Wandsworth have completed the RCGP drugs and alcohol management certificates to at least the part one level. This is the most recognised specialist substance misuse qualification in the UK. In addition, it should be noted that since Mr Hughes’ passing, HMP Wandsworth has employed a very experienced full time substance misuse practitioner, who oversees all of the five day review. This is the critical juncture to adjust the dosage and combination of sedating medications safely and consistently.” Source location Response from Oxleas NHS Foundation Trust
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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 Employ a full-time substance-misuse practitioner to oversee five-day reviews, quality assurance, audit, supervision and team development.
Verbatim wording from the response “2. The policy for the pharmacological treatment of drugs and alcohol withdrawal within the early days in custody has been reviewed, substantially revised and disseminated by the medicines management committee, with input from specialist substance misuse practitioners. It is a requirement that all prescribers of acute withdrawal medications at HMP Wandsworth have completed the RCGP drugs and alcohol management certificates to at least the part one level. This is the most recognised specialist substance misuse qualification in the UK. In addition, it should be noted that since Mr Hughes’ passing, HMP Wandsworth has employed a very experienced full time substance misuse practitioner, who oversees all of the five day review. This is the critical juncture to adjust the dosage and combination of sedating medications safely and consistently.” Source location Response from Oxleas NHS Foundation Trust
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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 Update the national service specification using learning from the case to strengthen prescribing and supply of sedating medicines.
Verbatim wording from the response “I am pleased to see from your Report that processes and procedures have been changed within HMP Wandsworth to address learning identified in this case and meet expectations in terms of prescribing and supplying sedating medicines safely.” Source location Response from NHS England
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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 Revise and disseminate the withdrawal-treatment policy, including sedation safeguards, tolerance assessment, urine screening and clinical review requirements.
Verbatim wording from the response “2. The policy for the pharmacological treatment of drugs and alcohol withdrawal within the early days in custody has been reviewed, substantially revised and disseminated by the medicines management committee, with input from specialist substance misuse practitioners. It is a requirement that all prescribers of acute withdrawal medications at HMP Wandsworth have completed the RCGP drugs and alcohol management certificates to at least the part one level. This is the most recognised specialist substance misuse qualification in the UK. In addition, it should be noted that since Mr Hughes’ passing, HMP Wandsworth has employed a very experienced full time substance misuse practitioner, who oversees all of the five day review. This is the critical juncture to adjust the dosage and combination of sedating medications safely and consistently.” Source location Response from Oxleas NHS Foundation Trust
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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 Discuss the case in a prescriber reflective-practice forum, focusing on individual history, clinical signs, investigations and cautious methadone dosing.
Verbatim wording from the response “3. This case has provoked a great deal of reflection on the balance of risks and benefits of methadone, especially in the first days of drug accumulation, and when prescribed alongside benzodiazepines or other sedatives. The findings and recommendations of Mr Hughes’ inquest have been shared with all prescribers. His case has already been discussed within a reflective practice forum for prescribers, focussing on the judicious interpretation of the individual patient’s history, clinical signs and investigations (such as urine drug screens), to prioritise safety with a ‘start low and go slow’ approach, even when this is unpopular with the patient.” Source location Response from Oxleas NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing competency requirements are considered sufficient; prescribing need not be restricted to substance misuse practitioners.
Verbatim wording from the response “Any clinician assessing and prescribing for substance misuse is expected to have the appropriate competencies to make and action clinical decisions independently. These decisions are made using the clinical system, information and evidence available to the clinician, to consider holistic health considerations. Referral to a colleague seeking advice or support is only necessary where a clinician is uncertain about what actions to take.” Source location Response from NHS England
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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 Employers, rather than NHS England, are responsible for ensuring clinicians’ competencies and training compliance.
Verbatim wording from the response “Responsibility for ensuring competencies is met lies with the clinician’s employer, most often the healthcare provider. This also applies to assuring training compliance.” Source location Response from NHS England
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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 National guidance already addresses reduced opioid tolerance and reducing or withholding methadone when sedation is present.
Verbatim wording from the response “4. That practitioners, when prescribing consider whether time spent in custody before remand, may have reduced an individual’s tolerance to opiates; this is especially when methadone is to be prescribed with a synergistic agent such as benzodiazepines.” Source location Response from NHS England
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1 Feb 2024 Joy EBANKS · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1
Failure to review prolonged prescribing of dependency-forming drugs and formulate dosage-reduction plans 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. 4
Kirby Road Surgery
Risk-score opioid and gabapentinoid patients, recall them for face-to-face structured medication reviews, and provide follow-up supporting safe dose reduction.
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Kirby Road Surgery
Recruit a specialist prescribing pharmacist with pain-clinic experience to conduct structured medication reviews.
View source
Kirby Road Surgery
Train three in-house clinical pharmacists with the specialist pharmacist to develop their capability to conduct structured medication reviews.
View source
Kirby Road Surgery
Update, externally review, approve and ratify the opioid and gabapentinoid prescribing policies.
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AI-generated summary
Joy EBANKS · 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
Joy Ebanks lived alone and was found unresponsive at home on 24 May 2023 after taking prescribed oxycodone and pregabalin for pain; she was pronounced deceased at the scene. The medical cause of death was oxycodone toxicity enhanced by pregabalin intake. The report raised concerns about very prolonged prescribing of two dependency-forming drugs, without evidence of a plan to reduce the dosages, and about the limited evidence for their long-term use in chronic pain.
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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 review prolonged prescribing of dependency-forming drugs and formulate dosage-reduction plans
Wider context from the report “[1] There was evidence of very prolonged prescribing of two dependency forming drugs with no evidence to suggest that a discussion had been had or plan had been formulated to reduce the dosages .
” Source location Joy EBANKS · 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 Risk-score opioid and gabapentinoid patients, recall them for face-to-face structured medication reviews, and provide follow-up supporting safe dose reduction.
Verbatim wording from the response “Our Clinical Lead Pharmacist identified, and risk scored all patients on opioid medications and also those on gabapentinoid medications to determine and recall individuals for a face-to-face structured medication review within a 28-day time period. These patients were then sent letters to inform them that their medication would be undergoing an upcoming review with a specialist prescribing pharmacist.” Source location Response from Kirby Road Surgery
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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 Recruit a specialist prescribing pharmacist with pain-clinic experience to conduct structured medication reviews.
Verbatim wording from the response “The Partners and Management Team sourced and recruited a specialist prescribing pharmacist (who has extensive experience of working in a pain clinic) to undertake the face-to-face structured medication reviews. Three of our inhouse clinical pharmacists are also undergoing training with our specialist prescribing pharmacist to enhance their skills and knowledge in this area to perform these reviews in the future.” Source location Response from Kirby Road Surgery
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train three in-house clinical pharmacists with the specialist pharmacist to develop their capability to conduct structured medication reviews.
Verbatim wording from the response “The Partners and Management Team sourced and recruited a specialist prescribing pharmacist (who has extensive experience of working in a pain clinic) to undertake the face-to-face structured medication reviews. Three of our inhouse clinical pharmacists are also undergoing training with our specialist prescribing pharmacist to enhance their skills and knowledge in this area to perform these reviews in the future.” Source location Response from Kirby Road Surgery
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update, externally review, approve and ratify the opioid and gabapentinoid prescribing policies.
Verbatim wording from the response “Our Opioid Prescribing Policy and our Gabapentinoid Prescribing Policy underwent updating and review by the Quality Assurance Manager to ensure all information was up to date. This was further reviewed by BLMK Medicines Management Matthew Davies to ensure compliance. Once recommended actions were implemented into policy, this was then signed off and ratified by” Source location Response from Kirby Road Surgery
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22 Jan 2024 Kate Elizabeth O’Donnell · Prevention of Future Deaths report Teesside and Hartlepool
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Concerns raised 1
Incorrect prescribing of prophylactic antibiotics after urology surgery View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Kate Elizabeth O’Donnell · 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
Kate Elizabeth O’Donnell underwent surgery on 16 March 2022 and was discharged the following day. She developed sepsis from the surgery, originating in her gut, and died at James Cook University Hospital on 23 March 2022. Principal concerns included inadequate surgical planning, failure to provide appropriate prophylactic antibiotics for the gastrointestinal surgery, insufficient postoperative vigilance and assessment before discharge, incomplete nursing records, and inadequate discharge information.
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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 Incorrect prescribing of prophylactic antibiotics after urology surgery
Wider context from the report “2. The consultant urologist did not know the results of pre-surgery urine test results and subsequently prescribed incorrect prophylactic antibiotics post urology surgery .
” Source location Kate Elizabeth O’Donnell · 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 Complete an antimicrobial-guidance compliance audit and share its findings with the relevant clinical collaborative.
Verbatim wording from the response “An audit of compliance with Trust antimicrobial guidance has been undertaken within the Digestive Diseases, Urology and General Surgery Services Collaborative throughout February 2024, which has identified areas for improvement in relation to antimicrobial prescribing. Detailed findings of the audit will be shared with the Collaborative in early April 2024, and this clinical risk will also be discussed within the Clinical Policy Group in April 2024, which is attended by senior Clinical Leaders from across the Trust.” Source location Response from South Tees Hospitals
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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 Update the Adult Antimicrobial Policy with links to the MicroGuide Antibiotic Prescribing Guidelines app.
Verbatim wording from the response “The Trust’s Adult Antimicrobial Policy will be updated by the end of April 2024 to include links to the MicroGuide Antibiotic Prescribing Guidelines app, which is a tool used to publish and provide easy access to local antimicrobial guidelines, to facilitate timely access to advice of effective and safe treatment of infections.” Source location Response from South Tees Hospitals
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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 Create electronic drug order sets for standardised first- and second-line surgical prophylactic antibiotic prescribing.
Verbatim wording from the response “Additionally, the Trust Pharmacy team will create specific drug order sets within the recently implemented Electronic Prescribing and Medicines Administration (ePMA) system, to support standardised and structured prescribing for first and second line prophylactic antibiotics following surgery. This will be completed by the end of April 2024.” Source location Response from South Tees Hospitals
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.