19 Mar 2026 Paul Robert Joseph NASH · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1
Difficulties obtaining sufficient quantities of epilepsy medication for continuous access View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Sundon Medical Centre
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
Department of Health and Social Care
Work with the pharmacy sector to improve awareness of emergency supply provisions and patients’ access to emergency medicines.
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Sundon Medical Centre
Consider repeat dispensing, batch prescribing, or one-off reserve prescriptions for suitable patients at risk of running out of critical medication.
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Sundon Medical Centre
Inform epilepsy patients about the Charlie Card emergency-supply self-advocacy tool.
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Sundon Medical Centre
Provide clear patient information about prescription processing and pharmacy dispensing times through the website and reception.
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Sundon Medical Centre
Clearly communicate the urgent status of critical-medication prescriptions to pharmacies to support prompt dispensing.
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Paul Robert Joseph NASH · 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 Robert Joseph NASH, who had epilepsy secondary to HSV encephalitis, was found deceased at home on 23 October 2025 after apparently suffering a seizure during the night. He had run out of Carbamazepine and missed three doses. The concerns included that the GP surgery did not appear to be told that he had completely run out of medication and did not prioritise the prescription for same-day collection, as well as wider difficulties for epilepsy patients in obtaining sufficient medication supplies.
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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 Difficulties obtaining sufficient quantities of epilepsy medication for continuous access
Wider context from the report “2. The Deceased's Consultant Neurologist indicated that many epilepsy patients across the country currently experience difficulties in obtaining sufficient quantities of medication to ensure optimum seizure control i.e. it is difficult for them to obtain batch quantities to ensure they always have access to some in the event that they find they are running low or there are delays in the pharmacy processing a repeat prescription (apparently in some areas processing can take up to 10 days) .
” Source location Paul Robert Joseph NASH · 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 Work with the pharmacy sector to improve awareness of emergency supply provisions and patients’ access to emergency medicines.
Verbatim wording from the response “The Department recognises that awareness of emergency supply provisions amongst both patients and pharmacy staff can be improved. The Department is committed to working with the pharmacy sector to improve awareness and ensure patients can access emergency supplies when necessary to prevent harm or death. We are currently in consultation with the sector representative body, Community Pharmacy England, on the 2026/27 Community Pharmacy Contractual Framework. As part of this consultation we will take into account learnings from Paul Nash’s death.” Source location 2026-0161 - Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider repeat dispensing, batch prescribing, or one-off reserve prescriptions for suitable patients at risk of running out of critical medication.
Verbatim wording from the response “Repeat dispensing / batch prescribing for suitable patients. For patients prescribed long term critical medication, the practice will consider whether repeat dispensing or batch prescribing with future dated repeat prescriptions for up to six months is appropriate, particularly where patients may have memory difficulties, cognitive impairment, or other vulnerabilities that place them at risk of running out of medication. This will be assessed on a case by case basis to ensure suitability and safety. Where patients have experienced difficulty obtaining medication on time the practice will consider prescribing a one-off extra medication prescription to provide patients with a month of their time critical medication in hand.” Source location Response from Sundon Medical Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inform epilepsy patients about the Charlie Card emergency-supply self-advocacy tool.
Verbatim wording from the response “Informing Epilepsy Patients of the Charlie Card - this is a self advocacy tool designed to assist individuals with epilepsy who find themselves without their regular anti-seizure medications. It highlights the legal framework under the Human Medicines Regulations 2012, allowing patients to request an emergency supply of anti-seizure medications from any pharmacy without a prescription, provided certain conditions are met. The card serves as a reminder to pharmacists of their legal duties and aims to ensure that patients can access life- saving medications quickly and efficiently. The Charlie Card is available free through the charity shop of SUDEP Action and individuals can also download a copy.” Source location Response from Sundon Medical Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide clear patient information about prescription processing and pharmacy dispensing times through the website and reception.
Verbatim wording from the response “Clear patient information regarding repeat turnaround times The practice will continue to ensure that patients are clearly informed that repeat prescriptions require a two working days for surgery processing and that pharmacies require additional time for dispensing. This information will be displayed on the website and in reception to encourage timely ordering and reduce the risk of medication running out.” Source location Response from Sundon Medical Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clearly communicate the urgent status of critical-medication prescriptions to pharmacies to support prompt dispensing.
Verbatim wording from the response “Pharmacy communication for urgent critical medication. Where a patient has run out of critical medication and an urgent prescription is issued, the practice will ensure that the urgent nature of the request is clearly highlighted with the pharmacy to support prompt dispensing.” Source location Response from Sundon Medical Centre
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing regulations and NHS pharmacy terms require community pharmacies to dispense NHS medicines with reasonable promptness and notify patients of delays.
Verbatim wording from the response “The Department recognises that delays in pharmacies processing repeat prescriptions can result in patients unexpectedly running out of vital medicines. That is why all community pharmacies providing dispensing services for NHS patients in England are required to dispense medicines for patients on demand with reasonable promptness. This is set out in regulations and within the terms of service for all pharmacies on the NHS Pharmaceutical list.” Source location 2026-0161 - Response from Department of Health and Social Care
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21 Jun 2024 Thomas Joseph GERAGHTY · Prevention of Future Deaths report East Sussex
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Concerns raised 1
Failure to review medication continuity when deregistering patients 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. 9
Chelsfield Surgery
Hold a Significant Event Analysis meeting to examine the deduction and agree learning points.
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Chelsfield Surgery
Update the Repeat Prescribing Policy to require adequate medication supply for removed patients until they register elsewhere.
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Chelsfield Surgery
Provide removed patients with a final-prescription letter explaining the need to register elsewhere for medication continuity.
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Chelsfield Surgery
Continue prescribing for removed patients with safeguarding concerns until registration elsewhere is confirmed, with any stopping decision made by a senior clinician and documented.
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Chelsfield Surgery
Circulate updated policies and SEA learning points to all non-clinical staff by email.
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Chelsfield Surgery
Hold a practice meeting for non-clinical staff to disseminate SEA conclusions and explain updated deduction procedures.
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Chelsfield Surgery
Audit deductions from the previous three years to identify affected patients and additional learning points.
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Chelsfield Surgery
Conduct monthly audits of future deductions and feed findings into weekly safeguarding meetings.
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Chelsfield Surgery
Review deductions involving safeguarding concerns in weekly safeguarding meetings and check that clinical needs and medication access are met.
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Thomas Joseph GERAGHTY · 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
Thomas Joseph Geraghty entered the sea from a beach at Eastbourne on 28 June 2023 and was later recovered from the water; resuscitation was unsuccessful and his death was confirmed. The inquest concluded suicide. The report raises concern that patients may be deregistered from GP surgeries without adequate review or communication to ensure continued access to vital medication, particularly where no new GP details are provided.
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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 medication continuity when deregistering patients
Wider context from the report “I have a concern that individuals can be removed from the surgery as patients without any scrutiny as to whether the individual may be receiving vital medication (either for a mental health or physical health issue). There does not appear to be any process of review in relation to these patients to ensure that they will continue to receive their medication after they are deregistered from the surgery . This is of particular concern where a patient is deregistered and the surgery has not been provided with details of an individual's new GP . There is a concern that in these circumstances, an individual may be left without access to medication, which could cause or contribute to their death.
” Source location Thomas Joseph GERAGHTY · 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 Hold a Significant Event Analysis meeting to examine the deduction and agree learning points.
Verbatim wording from the response “1. On 25 July 2024 the practice held a Significant Event Analysis (“SEA”) meeting. The details of Patient TG’s deduction from the list were presented and learning outcomes discussed. These included: a clinician should have been consulted before the deduction was submitted in November 2022, safeguarding considerations ought to have been raised and discussed with safeguarding lead, Patient TG ought to have been sent a further letter informing him of the deduction and Patient TG ought to have received advice about continuing his medication supply.” Source location Response from Chelsfield 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 Update the Repeat Prescribing Policy to require adequate medication supply for removed patients until they register elsewhere.
Verbatim wording from the response “3. We have also reviewed and updated our Repeat Prescribing Policy. Our Policy now states:” Source location Response from Chelsfield 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 Provide removed patients with a final-prescription letter explaining the need to register elsewhere for medication continuity.
Verbatim wording from the response “(b) We will now write to the patient to explain that this will be the final prescription from the practice and that the patient needs to register elsewhere to ensure continuity of their medication. In circumstances where there are safeguarding concerns, we will continue to prescribe medication until we receive confirmation that the patient has registered with a GP elsewhere. Any decision to then stop prescribing must usually be made by the safeguarding lead, or if they are unavailable then a senior clinician, and be clearly documented.” Source location Response from Chelsfield 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 Continue prescribing for removed patients with safeguarding concerns until registration elsewhere is confirmed, with any stopping decision made by a senior clinician and documented.
Verbatim wording from the response “(b) We will now write to the patient to explain that this will be the final prescription from the practice and that the patient needs to register elsewhere to ensure continuity of their medication. In circumstances where there are safeguarding concerns, we will continue to prescribe medication until we receive confirmation that the patient has registered with a GP elsewhere. Any decision to then stop prescribing must usually be made by the safeguarding lead, or if they are unavailable then a senior clinician, and be clearly documented.” Source location Response from Chelsfield 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 Circulate updated policies and SEA learning points to all non-clinical staff by email.
Verbatim wording from the response “4. The updated policies and learning points arising from the SEA have been circulated by email to all non-clinical staff. A practice meeting is scheduled on 14 August 2024 for all non-clinical staff to attend. The conclusions of the SEA will be disseminated to ensure that all staff learn from this case. We will highlight the updated policies and changes to procedure to ensure that there is no risk of repetition when deducting patients in the future.” Source location Response from Chelsfield 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 Hold a practice meeting for non-clinical staff to disseminate SEA conclusions and explain updated deduction procedures.
Verbatim wording from the response “4. The updated policies and learning points arising from the SEA have been circulated by email to all non-clinical staff. A practice meeting is scheduled on 14 August 2024 for all non-clinical staff to attend. The conclusions of the SEA will be disseminated to ensure that all staff learn from this case. We will highlight the updated policies and changes to procedure to ensure that there is no risk of repetition when deducting patients in the future.” Source location Response from Chelsfield 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 Audit deductions from the previous three years to identify affected patients and additional learning points.
Verbatim wording from the response “5. The Practice Manager is conducting an audit of all deductions which have taken place in the last 3 years. Through this audit we hope to ensure that no other patients have been affected by a deduction and to check if there are any additional learning points which arise.” Source location Response from Chelsfield 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 Conduct monthly audits of future deductions and feed findings into weekly safeguarding meetings.
Verbatim wording from the response “6. A continuing monthly audit will be undertaken by the Practice Manager for all patients deducted in the future. This audit will ensure that all deductions are appropriate, that any safeguarding concerns have been addressed and that the deduction does not disrupt continuity of care. The results of this audit will be fed into the safeguarding meetings which take place weekly (see below).” Source location Response from Chelsfield 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 Review deductions involving safeguarding concerns in weekly safeguarding meetings and check that clinical needs and medication access are met.
Verbatim wording from the response “7. The Safeguarding Lead GP will now review any patient deductions where there are safeguarding concerns in the weekly safeguarding meeting. These patients will be discussed and checks made to ensure that clinical needs are being met, particularly with respect to prescriptions / access to vital medication.” Source location Response from Chelsfield Surgery
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20 Jun 2014 Redmond Johnson · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Failure to arrange medication for periods when detainees are out of prison care View source
This report raised 6 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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Redmond Johnson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Redmond Johnson, aged 67, suffered a cardio-respiratory arrest while being transferred to Ipswich Crown Court on 25 November 2011 and died after transfer to Ipswich Hospital. The report identified concerns about the assessment of his fitness for transfer, including a record stating that he had no known medical risks despite the healthcare professional not having seen him. It also identified concerns about the management and documentation of his complex healthcare needs in custody, including liaison with community providers, specialist appointments, investigations, medication and care monitoring.
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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 arrange medication for periods when detainees are out of prison care
Wider context from the report “(5) There must be a robust and clearly documented process in place when assessing a detainee’s fitness to transfer, together with clear arrangements made in respect of any medication that the detainee needs to take while out of the prison’s care .
” Source location Redmond Johnson · Prevention of Future Deaths report
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Concerns raised 1
Failure to ensure continuity of required anticoagulation medication View source
This report raised 4 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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Leslie Edmund Harding (Lez) · Prevention of Future Deaths report
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Report summary
Leslie Edmund Harding had a history of multiple sclerosis and recurrent pulmonary emboli, and died after collapsing on 28 September 2013. The report raised concerns about the lack of action after he was assessed with chest pain and suspected pulmonary embolus, gaps in anticoagulation prescribing and follow-up, insufficient efforts to address alleged non-compliance, and the absence of a prompt significant events review.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure continuity of required anticoagulation medication
Wider context from the report “3. At Inquest, I gained the impression that Lez was felt to be non-compliant with his anti-coagulation regime. It was plain from the prescription history that there were repeated gaps in the provision of medication that Lez required . There seemed, however, in my view, to have been little effort given to addressing the reasons why, or indeed if, Lez actually was non-compliant with his medication. By way of illustration, I was not shown a letter from the Surgery to Lez bringing to his attention that he had failed to collect his monthly supply of Clexane and warning him of the risks of failing to maintain the treatment regime.
I heard evidence at Inquest that Lez could be an awkward patient. In my view, of itself, that is insufficient reason not to make every reasonable effort to ensure that a patient complies with an identified need for lifelong anti-coagulation.
” Source location Leslie Edmund Harding (Lez) · Prevention of Future Deaths report
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.