19 Sep 2019 Mark Jarvis · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Difficulty removing no-longer-needed prescriptions from the medication system View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mark Jarvis · 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
Mark Jarvis was found apparently deceased in his cell at HMP Warren Hill on 30 December 2015 and was later pronounced dead. The inquest concluded that the death resulted from a cardiac event precipitated by ingestion of a New Psychoactive Substance, with ischaemic heart disease recorded as the medical cause of death. Concerns included difficulties with the prison prescription system, including the inability to readily verify current and previous prescriptions, and the potential misuse of medications.
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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 Difficulty removing no-longer-needed prescriptions from the medication system
Wider context from the report “1. During the course of the inquest a GP who was responsible for medical care at HMP Warren Hill gave evidence in relation to the computer system, SytmOne which was used to review and prescribed medicines to the prisoners at the time of Mark’s death.
The court was told that the SystmOne online prescription ‘module’ was not clear to read or easy to understand and appeared incompatible with the prison’s own IT system.
The GP described that this left them in the situation of not being sure what a patient had been previously prescribed, not being sure what repeat prescriptions were in place and that they had no way of readily understanding what had been taken by a particular patient or when they were supposed to have taken it.
It was also explained that there was no direct link on the system between medications prescribed and previous diagnoses. Due to the time it took to navigate the records it was reported that some GP’s used their experience to identify a previous diagnosis from the repeat prescriptions recorded in the prescription module.
The GP further described that removing a prisoner’s prescription from the system when it was no longer necessary was very difficult.
One of the contributing factors the jury found to Mark’s death was directly related with poor adherence to his blood pressure medication regime on repeat prescription. Considering the difficulties GPs are facing when using the prescription module, and the testimony given by the GP in this case, it would appear there is no easy system for a doctor to verify exactly what their patient has already been prescribed and whether or not that prescription is still current.
Further, in relation to the potential misuse of drugs incorrectly or over-prescribed the GP explained that some medications, such as opioids or anti depression medication (including amitriptyline and sertraline) had ‘currency’ within the prison and it was known they would be traded by some prisoners. Therefore, not being able to readily identify what a prisoner should be, or already is being prescribed at the time of any specific consultation is again clearly a cause for concern.
In an interview the GP had with investigators from the Prisons and Probation Ombudsman’s Office on the 30th December 2015 (just one day after Mark’s death) the GP described the prescription module as “an absolute nightmare and we are banging our heads against a brick wall. We’re trying hard to get some changes done because we are concerned about safety”
When specifically questioned at the inquest on the 3rd September 2019 the GP stated that the situation as it stood at the end of December 2015 had still not been resolved.
” Source location Mark Jarvis · Prevention of Future Deaths report
Open source report
29 Jan 2019 Sophie Holman · Prevention of Future Deaths report London (East)
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Concerns raised 1
Failure to communicate changed asthma medication to primary care View source
This report raised 23 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
Sophie Holman · 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
Sophie Holman, a 10-year-old girl with chronic asthma, died on 13 December 2017 after collapsing during a severe asthma attack while being taken to hospital. The report identifies concerns about inadequate long-term management, fragmented records, failure to recognise the cumulative severity and risks of her asthma, lack of a coordinated asthma action plan and safety-netting, and missed opportunities for specialist referral.
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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 communicate changed asthma medication to primary care
Wider context from the report “In the secondary care there was:
a) Failure to recognise and act upon the underlying chronic condition punctuated by a number of severe attacks with life threatening features one of which was a near-fatal attack where Sophie was ‘blue and unresponsive’ with an oxygen saturation of 86% (2.7.2012)
b) Failure to recognise the need for and initiate referral of this child to a specialist respiratory service as recommended in the NRAD recommendations
c) Failure to take appropriate action when it was known that the family had a home nebuliser
d) Failure to implement the recommendations in the NICE Quality Statement 25, and BTS/SIGN guideline to ensure a pre-discharge review of the child’s asthma by an appropriately trained individual
e) Failure to effectively communicate changed medication in 2013 of the child to the general practitioner
f) Implementation of a hospital policy whereby this child was discharged from secondary care three times because of failure of the parents to bring the child to planned outpatient appointments
g) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-evidence based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication
” Source location Sophie Holman · Prevention of Future Deaths report
Open source report
19 Apr 2018 Amanda Mary Spark · Prevention of Future Deaths report Dorset
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Concerns raised 1
Lack of a policy for communicating medication regime changes and supervision to GPs or other treating practitioners 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
Amanda Mary Spark · 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 Mary Spark, who suffered with depression, was found collapsed and unresponsive at her home on 3 September 2017 and died from an overdose of prescribed medication. The inquest concluded that her death was suicide. The principal concern was that supervision applied to her mental health medication did not also cover prescribed physical health medication, and that there was no clear policy or communication process addressing this.
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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 Lack of a policy for communicating medication regime changes and supervision to GPs or other treating practitioners
Wider context from the report “iii. Evidence was given that although the GP is written to when there is a change in regime regarding the mental health medication, there is no action taken in relation to the physical health medication . This may be a matter for the GP to resolve but if a patient’s access to medication is to be immediately changed by DHUFT employees, this should be addressed in relation to all medication not just mental health medication.
iv. I heard evidence from the Psychiatric Liaison Team Lead and the Crisis Team Lead that there does not appear to be a policy in place at the Trust to deal with the communication of the supervision of physical health medication . If there is such a policy, they advised me that they are not aware of it.
v. Once the access to medication has been identified as a risk to a patient and there is a need for the taking of it to be supervised, access to, and the taking of, all medication, not just mental health medication, should be supervised.
2. I have concerns with regard to the following:
i. That there is no policy in place in relation to the supervision of prescribed physical health medication when a decision has been made to supervise the administration of prescribed mental health mediation. I would therefore request that DHUFT review their policies regarding the supervision of all medication a patient is prescribed and when and how to alert GPs, or other treating practitioners, regarding changes to mediation regimes and supervision .
ii. If there is already such a policy in place to deal with both physical health and mental health mediation, then I would request that refresher training is undertaken to ensure all staff are made aware of the policy and the procedures to be adapted in such circumstances.
” Source location Amanda Mary Spark · Prevention of Future Deaths report
Open source report
27 Mar 2018 Maureen Anne CAMPBELL-SCOTT · Prevention of Future Deaths report London (East)
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Concerns raised 1
Inability of GPs to implement rapid and accurate specialist-directed medication changes View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
North East London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
North East London NHS Foundation Trust
Email medication changes to GPs within 24 working hours.
View source
North East London NHS Foundation Trust
Require doctors to include their telephone number on medication-change notifications sent to GPs.
View source
North East London NHS Foundation Trust
Compile and redistribute NELFT consultant psychiatrists’ telephone numbers to Redbridge GPs so they can contact prescribing clinicians.
View source
North East London NHS Foundation Trust
Continue joint NELFT–Fullwell Cross meetings to agree the process for referrals, prescribing during medication changes and communication, including reconvening to resolve prescribing responsibilities.
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AI-generated summary
Maureen Anne CAMPBELL-SCOTT · 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
Maureen Anne Campbell-Scott died from multiple injuries after falling from a ledge at the Exchange Shopping Centre car park on 16 June 2017. The report identified concerns about delays and errors in mental health referrals, delayed communication of medication changes, prescribing that did not always follow specialist directions, and a lack of joint working between mental health services and the GP practice.
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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 Inability of GPs to implement rapid and accurate specialist-directed medication changes
Wider context from the report “(4) In times of acute mental health crisis, medication if often rapidly changed/supplemented. Mrs Campbell-Scott had 7 changes in her medication regime between 21 November 2016 to 23 February 2017. It is challenging for GPs to be able to ensure rapid and accurate changes when medication changes are directed by the specialist team.
” Source location Maureen Anne CAMPBELL-SCOTT · 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 Email medication changes to GPs within 24 working hours.
Verbatim wording from the response “2b | NELFT Action | Medication changes to be emailed to GP within 24 working hours. | NELFT Dr Shweta Anand | 18/05/18 | Completed” Source location 2018-0090-Response-by-NELFT
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require doctors to include their telephone number on medication-change notifications sent to GPs.
Verbatim wording from the response “2c | NELFT Action | All Doctors to add their telephone number to the bottom of ‘change of medication notification’ | NELFT Dr Shweta Anand | 18/05/18 | Completed” Source location 2018-0090-Response-by-NELFT
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 Compile and redistribute NELFT consultant psychiatrists’ telephone numbers to Redbridge GPs so they can contact prescribing clinicians.
Verbatim wording from the response “We have already agreed to provide personal contact details of NELFT Consultant’s to GPs for additional support and this action is already in place to allow GP’s to access advice regarding the management of people who have mental health problems. NELFT attended a very successful event with all Redbridge GP’s last week, where our staff did a series of table presentation to the GP’s. The theme was around mental health services and the crisis care pathway. We believe this will aid our future joint working with GP’s within the borough. The event was coordinated by ████████ who is the BHR CCG Lead GP for Mental Health. At the event he briefed GP’s regarding future communication methods and that all communication will move to being electronic in line with the action plan in relation to this regulation 28.” Source location 2018-0090-Response-by-NELFT
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 Continue joint NELFT–Fullwell Cross meetings to agree the process for referrals, prescribing during medication changes and communication, including reconvening to resolve prescribing responsibilities.
Verbatim wording from the response “We have had two meetings with the Fullwell Cross Practice and believe that we had agreed a process regarding the prescribing of medication to our shared patients. It was only on Tuesday of this week that we were informed that the practice had some late reservations about this specific aspect of the joint action plan. As such we are reconvening a meeting with Primary Care Colleagues to discuss the position further and agree a way forward.” Source location 2018-0090-Response-by-NELFT
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 NELFT cannot undertake prescribing because prescribers lack an overview of patients’ full medication and may miss interactions or contraindications.
Verbatim wording from the response “We understand that Fullwell Cross Medical Centre are now of the view that NELFT should undertake the prescribing duty, whereas our clinicians advise this is not practical for a number of reason, these broadly being the following:” Source location 2018-0090-Response-by-NELFT
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 NELFT cannot undertake prescribing because it lacks arrangements with community pharmacists to ensure frail patients receive medication.
Verbatim wording from the response “We understand that Fullwell Cross Medical Centre are now of the view that NELFT should undertake the prescribing duty, whereas our clinicians advise this is not practical for a number of reason, these broadly being the following:” Source location 2018-0090-Response-by-NELFT
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 NELFT cannot use FP10 prescribing for many Older Adult Mental Health Team patients who lack capacity.
Verbatim wording from the response “We understand that Fullwell Cross Medical Centre are now of the view that NELFT should undertake the prescribing duty, whereas our clinicians advise this is not practical for a number of reason, these broadly being the following:” Source location 2018-0090-Response-by-NELFT
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 NELFT cannot facilitate compliance aids through local pharmacists, so medication for patients using them must be organised by GPs.
Verbatim wording from the response “We understand that Fullwell Cross Medical Centre are now of the view that NELFT should undertake the prescribing duty, whereas our clinicians advise this is not practical for a number of reason, these broadly being the following:” Source location 2018-0090-Response-by-NELFT
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 NELFT cannot undertake FP10 prescribing for many patients in care or sheltered accommodation because those settings will not accept such prescriptions.
Verbatim wording from the response “We understand that Fullwell Cross Medical Centre are now of the view that NELFT should undertake the prescribing duty, whereas our clinicians advise this is not practical for a number of reason, these broadly being the following:” Source location 2018-0090-Response-by-NELFT
Open published response
26 Jul 2017 Songul BOZDAG · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to update drug cards to reflect increased prescriptions View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Songul BOZDAG · 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
Songul Bozdag, who had schizophrenia and other mental health conditions, died after jumping from a tenth-floor window on 9 February 2017. Concerns included missed mandatory reviews, incomplete recording of consultations, failure to record a required care plan approach, an incorrect drug card that left her under-medicated, and the absence of a system safety net to identify these errors.
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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 update drug cards to reflect increased prescriptions
Wider context from the report “1. Ms Bozdag’s care co-ordinator did not arrange for what was a mandatory say review of Ms Bozdag after discharge from hospital in August/September 2016.
2. She recorded monthly reviews of Ms Bozdag on only half of the months from September 2016 to Ms Bozdag’s death in February 2017, though monthly reviews were mandatory.
3. The care co-ordinator gave evidence at inquest that she had actually reviewed Ms Bozdag once a fortnight when Ms Bozdag came for her depot injections, but in the main did not record these discussions. She did include in her statement for the court one note recording the nature of a discussion had on 10 February. This was in fact the day after death. She said this was an error.
4. She described having a very good recollection of individual consultations with Ms Bozdag, such as one on 6 September 2016 though there was no record supporting this description. However, she had not had a sufficient recollection of Ms Bozdag’s treatment during her life to notice that the need for a care plan approach (CPA) had not been recorded on the computer system.
5. Finally, the care co-ordinator did not ensure that the drug card in use reflected the psychiatrist’s increased prescription of 50mg of risperidone rather than the original one of 37.5mg . Ms Bozdag was therefore under medicated on an ongoing basis .
These were the errors of an individual, but there is an additional point that they were not captured by any sort of system safety net during Ms Bozdag’s life.
” Source location Songul BOZDAG · 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 Implement a central referrals inbox for communicating hospital discharge plans to CMHT staff, with daily administrative review and senior oversight.
Verbatim wording from the response “There is now a new Operational Team Lead in post and this member of staff has imbedded robust systems within the CMHT. The first change is the implementation of an Inbox based system to communicate discharge care plans to CMHT staff.” Source location Response from East London 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 Require Senior Practitioners to allocate and monitor discharge-plan actions, using duty workers when care coordinators are unavailable.
Verbatim wording from the response “Senior Practitioners are now responsible for ensuring that actions arising from discharge plans are allocated to care coordinators and monitored to ensure they have been followed up. This will include seven day follow ups, medical reviews and changes in medication. This new process will also allow senior practitioners to allocate actions to a duty worker if the care coordinator is absent from work or unable to undertake an intervention for any reason.” Source location Response from East London NHS Foundation Trust
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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 Implemented CMHT systems are considered sufficient to address concerns about monitoring care coordinators.
Verbatim wording from the response “With the systems that are now implemented at the CMHT I hope you will be content that the Trust has taken these issues seriously and adequately addressed your concerns.” Source location Response from East London NHS Foundation Trust
Open published response
10 Mar 2017 Lester John STACEY · Prevention of Future Deaths report Staffordshire South
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Concerns raised 1
Failure to monitor medication after changes during admission View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Lester John STACEY · 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
Lester John STACEY, who had hypertrophic cardiomyopathy and bipolar affective disorder, was found hanging in a barn at his home on 23 October 2016 and was certified dead at the scene. Concerns included discharge from mental health inpatient care without follow-up appointments, no attempted visit to re-engage him with services, and a change in medication that does not appear to have been monitored.
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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 monitor medication after changes during admission
Wider context from the report “The deceased was admitted as an In-patient under S2 Mental Health Act from 16 May 2016 to 19 May 2016. He was discharged without being given follow up appointments. He subsequently failed to respond to telephone calls and letters to attend appointments. He was therefore discharged from the service on the 21 June 2016.
There was no attempt to visit him during this period to try and re-engage him with services. He may not have received the correspondence inviting him for appointments because he was away on holiday for some of that period. He might have benefitted from having pre-arranged appointments prior to his discharge. His medication was changed during his last admission and thereafter does not appear to have been monitored. The deceased was said to have lacked confidence in the new medication and may not have been totally compliant. Family perception was that he responded less well to the changed medication.
” Source location Lester John STACEY · Prevention of Future Deaths report
Open source report
14 Feb 2017 Derek LEE · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Failure to discuss medication changes View source
This report raised 25 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
Derek LEE · 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
Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.
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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 discuss medication changes
Wider context from the report “(11) It was not until the 12th May – two weeks after Mr Lee’s admission to Brunswick Ward – that he was seen by the Parkinson’s Nurse Specialist. When the Specialist Nurse saw Mr Lee he made three important recommendations and asked for feedback within seven days – the referral to the Speech and Language Therapy Team was done the next day.
The enema did not take place for two days. Too long and possibly dangerous.
The change in medication was never even discussed.
” Source location Derek LEE · Prevention of Future Deaths report
Open source report
10 Aug 2016 Thomas George Jordan · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to discontinue prescribed medication when requested by hospital clinicians View source
This report raised 3 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
Thomas George Jordan · 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 George Jordan, a remand prisoner at Her Majesty’s Prison, Leeds, became unwell with cardiac symptoms and was admitted to hospital on 6 August 2015. His condition deteriorated, and he died following cardiac arrest at 1955 hours that day; the inquest recorded natural causes. The concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication when he was discharged from hospital, although the report stated there was no evidence that the drug error materially caused or contributed to his death.
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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 discontinue prescribed medication when requested by hospital clinicians
Wider context from the report “(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued .
(2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged.
(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them.
(4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death.
” Source location Thomas George Jordan · Prevention of Future Deaths report
Open source report
6 Aug 2015 THOMAS THEO CHARLES THURLING · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2
Failure to communicate medication changes and monitoring requirements to involved carers and family View source Failure to provide timely and continuous monitoring following medication changes View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Norfolk and Suffolk NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Norfolk and Suffolk NHS Foundation Trust
Share medication-change monitoring concerns with Pharmacy, Triangle of Care leads and clinical teams for learning to be cascaded.
View source
Norfolk and Suffolk NHS Foundation Trust
Provide Pharmacy support for medication information to service users and families, including a medicines information helpline.
View source
Norfolk and Suffolk NHS Foundation Trust
Monitor patient surveys, incident reports and complaints for failures to communicate treatment changes, taking remedial action where required.
View source
Norfolk and Suffolk NHS Foundation Trust
Raise medication-change monitoring directly with clinical staff through internal communications and clinical forums.
View source See 1 more action
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THOMAS THEO CHARLES THURLING · 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 Theo Charles Thurling, who had increasing depression, anxiety and suicidal ideation, was found dead at home on 28 October 2014 after he did not respond to visits. The inquest concluded that he took his own life, with medical cause of death recorded as asphyxiation. Concerns included medication changes not being adequately monitored, a prolonged absence of his Care Co-ordinator without alternative cover or review, and staff shortages.
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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 communicate medication changes and monitoring requirements to involved carers and family
Wider context from the report “(1) On 13 August 2014 Mr Thurling's medication was changed to help his low mood and anxiety. The Psychiatrist specifically stated that the change in medication was to be monitored to include the involvement of the CRHT Team. One Psychiatrist gave evidence (which was read) that the change in medication was closely monitored by Mind. Mr Thurling later declined any input from the CRHT Team. His Care Co-Ordinator was unaware of the symptoms to look for . Despite close involvement, Mr Thurling's family were unaware of the change in medication and the request for monitoring .
Although Mr Thurling was seen daily by Mind they were unaware of any change in medication and the request for monitoring .
An Out Patient Review was not arranged until 6 weeks later.
Following that Out Patient Review the Care Co-Ordinator was absent from work on planned and unplanned leave. Nothing was put in place for monitoring the medication.
” Source location THOMAS THEO CHARLES THURLING · 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 provide timely and continuous monitoring following medication changes
Wider context from the report “(1) On 13 August 2014 Mr Thurling's medication was changed to help his low mood and anxiety. The Psychiatrist specifically stated that the change in medication was to be monitored to include the involvement of the CRHT Team . One Psychiatrist gave evidence (which was read) that the change in medication was closely monitored by Mind. Mr Thurling later declined any input from the CRHT Team. His Care Co-Ordinator was unaware of the symptoms to look for. Despite close involvement, Mr Thurling's family were unaware of the change in medication and the request for monitoring.
Although Mr Thurling was seen daily by Mind they were unaware of any change in medication and the request for monitoring.
An Out Patient Review was not arranged until 6 weeks later .
Following that Out Patient Review the Care Co-Ordinator was absent from work on planned and unplanned leave. Nothing was put in place for monitoring the medication .
” Source location THOMAS THEO CHARLES THURLING · 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 Share medication-change monitoring concerns with Pharmacy, Triangle of Care leads and clinical teams for learning to be cascaded.
Verbatim wording from the response “In considering the means by which to ensure this practice is consistent, no single action will provide assurance. Recognising the task involves technical knowledge of medication and an understanding of the need to communication to the wider group of people involved in supporting the service user, we are sharing the issue with a range of leads in specific areas, such as the Pharmacy and those leading the implementation of Triangle of Care, as well as clinical teams. They will use this direction to cascade learning.” Source location 2015-0309-Response-by-Norfolk-and-Suffolk-NHS-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 Provide Pharmacy support for medication information to service users and families, including a medicines information helpline.
Verbatim wording from the response “Positively, many of our inpatient services have processes in place where the Pharmacy directly assist with providing information on medication to service users and their families. They also host a medicines information helpline which is available for service users and carers to use.” Source location 2015-0309-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 patient surveys, incident reports and complaints for failures to communicate treatment changes, taking remedial action where required.
Verbatim wording from the response “The most direct means by which the Trust will know it is consistently involving all parties in communication of changes to the service user's treatment is through measures such as the patient survey, incident reporting and complaints. The Trust will monitor specifically for this type of report taking remedial action where required.” Source location 2015-0309-Response-by-Norfolk-and-Suffolk-NHS-Trust
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 Raise medication-change monitoring directly with clinical staff through internal communications and clinical forums.
Verbatim wording from the response “Further, the matter will be raised directly with clinical staff via internal communications and clinical forums.” Source location 2015-0309-Response-by-Norfolk-and-Suffolk-NHS-Trust
Open published response
22 Apr 2015 Laurence Boyens · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1
Failure to cancel discontinued medication prescriptions in the computerised record View source
This report raised 11 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
Laurence Boyens · 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
Laurence Boyens died in prison on 15 November 2012 from Methadone, Tramadol and Diazepam intoxication. The jury identified concerns about the combination and interaction of prescribed drugs, failures to monitor intoxication symptoms and blood pressure, and failures to suspend or withhold Methadone and Tramadol when signs of toxicity were present.
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 cancel discontinued medication prescriptions in the computerised record
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison.
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam.
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered.
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered .
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” Source location Laurence Boyens · Prevention of Future Deaths report
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