23 Oct 2019 Kenneth John Daly · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Unclear prescribing advice for concurrent pain-relieving medications View source Failure to seek clarification of unclear prescribing advice 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
Kenneth John Daly · 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
Kenneth John Daly, who had chronic pain and anxiety and was prescribed multiple medications, was found dead at home on 4 December 2018. The inquest concluded that his death was drug related, involving multi-drug toxicity, after he overdosed on Morphine, Dihydrocodeine and Codeine alongside Pregabalin and benzodiazepine medication. Concerns included unclear guidance about using multiple opioid medications together and the absence of tailored written advice for Mr Daly.
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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 Unclear prescribing advice for concurrent pain-relieving medications
Wider context from the report “1) In oral evidence, the Consultant stated that no other opioids were to be taken once Morphine Sulphate and Co-Codamol had been prescribed but that prescribing of Pregabalin could continue. She set out her advice in a letter to Mr Daly’s GP dated 11 July 2018. The letter clearly stated that Fentanyl and Tapentadol should be stopped and Morphine sulphate (MST) 60mg started. The advice regarding the prescribing of pain relieving medications other than Fentanyl and Tapentadol is less clear. In relation to Dihydrocodeine and Tramadol it is stated that “He can continue using the Dihydrocodeine and very rarely Tramadol until he sees you for his next prescription. Together with the MST, I would recommend to allow him Co-Codamol 30/500mg 2 tablets up to four times a day...”. Following receipt of the letter, Tramadol and Dihydrocodeine continued to be issued by the GP practice albeit at lower quantities than previously prescribed. The GP did not seek any further guidance regarding the advice given in the letter of 11 July 2018 from the Consultant.
2) Mr Daly was a patient that was known to adjust his pain medication without seeking guidance from his GP. Whilst Mr Daly was copied in to the letter sent to his GP on 11 July 2018, he was not given any written guidance regarding his pain relief and the use of other medications (such as benzodiazepines) that was tailored to his needs as a patient.
Specifically, he was not given any written advice regarding the risks of using multiple opioid medications in combination.
” Source location Kenneth John Daly · 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 seek clarification of unclear prescribing advice
Wider context from the report “1) In oral evidence, the Consultant stated that no other opioids were to be taken once Morphine Sulphate and Co-Codamol had been prescribed but that prescribing of Pregabalin could continue. She set out her advice in a letter to Mr Daly’s GP dated 11 July 2018. The letter clearly stated that Fentanyl and Tapentadol should be stopped and Morphine sulphate (MST) 60mg started. The advice regarding the prescribing of pain relieving medications other than Fentanyl and Tapentadol is less clear. In relation to Dihydrocodeine and Tramadol it is stated that “He can continue using the Dihydrocodeine and very rarely Tramadol until he sees you for his next prescription. Together with the MST, I would recommend to allow him Co-Codamol 30/500mg 2 tablets up to four times a day...”. Following receipt of the letter, Tramadol and Dihydrocodeine continued to be issued by the GP practice albeit at lower quantities than previously prescribed. The GP did not seek any further guidance regarding the advice given in the letter of 11 July 2018 from the Consultant.
2) Mr Daly was a patient that was known to adjust his pain medication without seeking guidance from his GP. Whilst Mr Daly was copied in to the letter sent to his GP on 11 July 2018, he was not given any written guidance regarding his pain relief and the use of other medications (such as benzodiazepines) that was tailored to his needs as a patient.
Specifically, he was not given any written advice regarding the risks of using multiple opioid medications in combination.
” Source location Kenneth John Daly · Prevention of Future Deaths report
Open source report
30 Sep 2019 Graham Earl · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to refer prescription amendments to the secondary care doctor for medication not started in primary care 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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AI-generated summary
Graham Earl · 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
Graham Earl had pulmonary fibrosis diagnosed while receiving Amiodarone therapy and was not referred back to the cardiologist. He later developed influenza, deteriorated, and died at Stepping Hill Hospital on 16 February 2019. The principal concerns were that the link between Amiodarone and pulmonary fibrosis was not recognised promptly, the medication was amended without reference to secondary care, and there was insufficient awareness of escalation procedures for side effects.
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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 refer prescription amendments to the secondary care doctor for medication not started in primary care
Wider context from the report “2. A GP amended the prescription subsequently without reference to the secondary care doctor despite the fact that this is not a medication started in primary care ;
” Source location Graham Earl · Prevention of Future Deaths report
Open source report
19 Sep 2019 Kathryn Mary Barrow · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to verify mental health service advice before prescribing Diazepam 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
Kathryn Mary Barrow · 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
Kathryn Mary Barrow was found dead at her home on 7 March 2019, aged 59, after a long history of mental illness and treatment for bipolar affective disorder. A post-mortem did not establish a medical cause of death, and the inquest recorded an Open conclusion. Concerns related to the prescribing of Diazepam, including inadequate documentation or checks, whether access to the medicine illicitly had been considered, and the practice’s lack of a recent review of its prescribing approach.
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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 verify mental health service advice before prescribing Diazepam
Wider context from the report “1. Having claimed this has been advised by her Consultant Psychiatrist, Mrs Barrow has obtained short course prescriptions for Diazepam from the surgery apparently without further documentation being received from mental health services to confirm this , or without further checks being made by the GP ;
” Source location Kathryn Mary Barrow · Prevention of Future Deaths report
Open source report
4 Jul 2019 Miriam Tighe · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of information sharing between GPs and psychiatrists about sedative and antipsychotic medication decisions 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
Miriam Tighe · 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
Miriam Tighe became a resident of Edge Hill Residential Home in August 2016 and later received hospital and residential nursing care before passing away on 28 February 2017. The report identified concerns that promazine and other sedative or antipsychotic medication continued to be prescribed and administered despite advice to stop promazine, and that communication between GPs and a psychiatrist was insufficient, leading to unsafe prescribing. The investigation recorded that her death followed naturally occurring disease, with high levels of sedation and immobility in the preceding months worsening her frailty.
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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 information sharing between GPs and psychiatrists about sedative and antipsychotic medication decisions
Wider context from the report “Promazine was sought by the home manager at Edge Hill Residential Home and prescribed by the GPs at Royton & Crompton family practice after ████████ (Psychiatrist working in the Memory Clinic (part of Pennine Care NHS Foundation Trust)) had advised that such medication be stopped on the 16th November 2016 and, again on the 16th December 2016. On both occasions, promazine continued to be prescribed by the GP and continued to be administered under the control of the manager at Edge Hill Residential Home. In the event, I found that Miriam Tighe had been over-sedated during her time as a resident at Edge Hill Residential Home. The psychiatrist had recommended alternative sedative and antipsychotic medication, which was also administered to Miriam Tighe. It was clear that the GPs and the Psychiatrist were not aware of decisions being made by each other in October to December 2016 , which led to unsafe prescribing of sedatives and antipsychotic medication .
” Source location Miriam Tighe · Prevention of Future Deaths report
Open source report
27 Feb 2019 Peter George Garvin · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Lack of doctor-to-doctor communication for prescribing 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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AI-generated summary
Peter George Garvin · 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
Peter George Garvin, who was under the care of a Community Mental Health Team while his medication was prescribed by his GP, entered the Regent’s Canal on 31 January 2018 with the intention of taking his own life. The report identifies concerns about communication between the CMHT and GP, insufficient local psychiatric beds, discharge from NHS care after seeking private psychiatric treatment, and the lack of an early carer’s assessment.
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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 Lack of doctor-to-doctor communication for prescribing
Wider context from the report “1. That there should be a system of doctor to doctor communication to facilitate prescribing , for example through direct email contact.
” Source location Peter George Garvin · 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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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
30 Aug 2018 Michael John Drewell · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to follow senior clinician anticoagulant-duration advice View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Michael John Drewell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael John Drewell fell from his bike while travelling to work on 16 November 2017, sustained a hip fracture, and underwent surgery. He later suffered a cardiac arrest at home and died on 22 December 2017 from a pulmonary thromboembolism, likely a complication of the hip surgery. The concerns were that a Senior Clinician’s advice for six weeks of Tinzaparin was not followed and was not recorded in the electronic notes, resulting in a four-week prescription that ended two days before his death.
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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 follow senior clinician anticoagulant-duration advice
Wider context from the report “The treating Consultant advised that Mr Drewell, because of his height and weight, be given anti-coagulant Tinzaparin for six weeks rather than four weeks as was usual. He recorded his advice on the handwritten records at hospital following a ward round the day after surgery.
When the Junior Doctor came to prescribe Tinzaparin several days later he likely did not consult the handwritten notes and only prescribed four weeks Tinzaparin immediately before Mr Drewell’s discharge from hospital.
Evidence was heard that Junior Doctors would not be expected to consult the handwritten notes when prescribing drugs in accordance with NICE Guidelines.
It is of concern that the advice of a Senior Clinician was not followed and, further, that his advice was not placed upon the electronic notes.
” Source location Michael John Drewell · Prevention of Future Deaths report
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 Record post-discharge Tinzaparin instructions on electronic drug charts and transfer them automatically to electronic discharge advice notes for eligible patients.
Verbatim wording from the response “I can reassure you that good practice is already embedded within many clinical areas throughout the Trust. For example, Elderly Medicine patients with pelvic fractures who are being discharged to care in the community (CIC) beds have Tinzaparin continued until they are weight bearing after discharge. An instruction to this effect is added to the electronic drug chart and this information is then pulled through automatically to the EDAN. In addition, our pharmacists will also add electronic notes regarding discharge medication advice following multi-disciplinary team meetings with treating clinicians.” Source location 2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
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 Trust determined that Tinzaparin was correctly prescribed under NICE guidance, and a longer course could not be shown to have prevented death.
Verbatim wording from the response “At the inquest it was accepted that it was not possible to say that the ending of the prescription more than minimally contributed to his death. The Trust provided a root cause analysis summary that concluded that the correct dose of Tinzaparin had been prescribed for a gentleman of Mr Drewell’s height and weight and that there had been no lapses in care. Tinzaparin was prescribed at discharge according to NICE guidance. The trust has therefore determined that, notwithstanding the request by an individual consultant, Tinzaparin was correctly prescribed for Mr Drewell and it is not possible to say that a longer course of the anticoagulant would have prevented his death.” Source location 2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
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 Comprehensively reviewing the entire medical record before electronic discharge prescribing is considered impractical for junior doctors.
Verbatim wording from the response “In your Regulation 28 Report you highlight the fact that the junior doctor did not consult the hand-written medical records before prescribing the anticoagulant medication. I am sure that you will agree that it is impractical for junior doctors to comprehensively review the medical record in its entirety when completing the electronic discharge advice note (EDAN) and prescription. It is therefore imperative that if individual clinicians decide to prescribe ‘off protocol’ they either action this themselves personally, or leave clear unambiguous instructions within the electronic record. This can be done in two ways; either the eMeds electronic prescribing chart can be annotated or the EDAN can be pre-populated with specific discharge advice.” Source location 2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
27 Mar 2018 Maureen Anne CAMPBELL-SCOTT · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 1
Failure of GP prescribing to follow psychiatric team direction 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.
View source See 1 more action
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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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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of GP prescribing to follow psychiatric team direction
Wider context from the report “(3) The prescribing by the GP did not always follow the direction given by the psychiatric 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require 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
Concerns raised 1
Failure to review and act on specialist medication advice 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
Pauline May Pryor · 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
Pauline May Pryor, a resident of Trevornor Nursing Home receiving lithium treatment, was found unwell on 9 July 2015 and died in hospital on 13 July 2015. The report identified concerns that required quarterly blood tests were not carried out because of unclear communication between the nursing home and GP surgery, and that psychiatric advice to reduce and stop lithium was not seen or followed up.
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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 and act on specialist medication advice
Wider context from the report “• Mrs Pryor suffered from bipolar affective disorder and was on Lithium treatment which had been successful for many years in controlling her mood. Patients on Lithium are required to have quarterly blood tests to check kidney function and lithium levels. This was not carried out for a number of reasons do to with unclear communication between the Nursing Home and GP surgery. The practice did have in place a computer system to highlight test/reviews for certain groups of patients based on “Quality Outcome Framework Targets” (QOF) guidelines and were unaware these did not necessarily mirror the NICE Guidelines or Local Prescribing /Care Guidelines such as in the case of Lithium Toxicity
• A blood test on 29th April 2015 showed Mrs Pryor’s kidney function dropped (eGFR 25) despite a lithium test being requested by Nursing Home and GP it did not occurred. As a result of the kidney function test result the GP wrote to Mrs Pryor’s Consultant Psychiatrist for advice on medication. The Psychiatrist replied by e-mail on the 15.6.15 and advised the GP to reduce and stop the Lithium medication. The E-mail was sent to the GP Practice e-mail but was not seen by the GP for reasons unknown nor was the reply chased up
” Source location Pauline May Pryor · Prevention of Future Deaths report
Open source report
27 Jul 2017 Percy Jacks · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Reliance of GP prescribing on receipt of hospital scan-result notification View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission Hywel Dda University LHB RHAYADER GROUP PRACTICE
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Hywel Dda University LHB
Implement a streamlined DVT pathway directing suspected cases to radiology, initiating primary treatment before ultrasound, and ensuring positive and negative results receive appropriate follow-up.
View source
RHAYADER GROUP PRACTICE
Record all suspected DVT referrals and follow up 48 hours later to confirm receipt of results.
View source
Care Quality Commission
Review how inspections assess timely information transfer between services, using policy, medicines and clinical expertise.
View source
Care Quality Commission
Revise and improve the wording of the Key Lines of Enquiry on information sharing during transfers between services.
View source
Care Quality Commission
Have inspectors use two specific information-sharing questions when reviewing practice safety from November 2017.
View source See 2 more actions
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AI-generated summary
Percy Jacks · 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
Percy Jacks died from a pulmonary embolus after being found unresponsive the morning following treatment for chest pain. The report identified failings in the management of his anticoagulation medication, including poor communication between the hospital, GP surgery and care home, and inadequate systems for ensuring the medication continued for the intended period.
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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 Reliance of GP prescribing on receipt of hospital scan-result notification
Wider context from the report “(2) The system within the GP surgery for prescribing Rivaroxaban was poor and relied solely on receiving the notification of the results of the scan from the hospital . There was no facility to review the medication to ensure that the correct dosage for the correct period of time continued to be prescribed.
” Source location Percy Jacks · 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 streamlined DVT pathway directing suspected cases to radiology, initiating primary treatment before ultrasound, and ensuring positive and negative results receive appropriate follow-up.
Verbatim wording from the response “The process of managing potential DVT patients has been streamlined and a definite pathway introduced. All GP referrals which suspected DVTs are referred direct to the Hospital's Radiology Department as per the attached protocol. It is incumbent on the GPs to commence their primary prior to an ultrasound scan being undertaken. Following their scan, if the result is positive, the patient is referred back to the A & E Department where they are reviewed by the on-call Physicians. There is a pre-printed letter that is completed by the on-call physicians to the GP with recommendations and this is also copied to the Anticoagulation Clinic. If the result of the scan is negative, the patient is referred back to their GP for further evaluation.” Source location 2017-0329-Response
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 Record all suspected DVT referrals and follow up 48 hours later to confirm receipt of results.
Verbatim wording from the response “We have discussed this in our practice meeting and have made the following changes.” Source location 2017-0329-Response-by-Rhayader-Group-Practic
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 how inspections assess timely information transfer between services, using policy, medicines and clinical expertise.
Verbatim wording from the response “As a result of the concerns being brought to our attention we have taken the opportunity to review how CQC checks that information about patients being transferred between services happens in a timely manner and whether there is any more we as a regulator can do to prevent an incident such as this from happening in future.” Source location 2017-0329-Response-by-Care-Quality-Commission
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 Revise and improve the wording of the Key Lines of Enquiry on information sharing during transfers between services.
Verbatim wording from the response “We have revised and improved the wording of our Key Lines of Enquiry and from November 2017 inspectors will be considering the following two specific questions when they are reviewing the safety of a practice, instead of one being a prompt supporting the other: ‘When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?’ and ‘How well do the systems that manage information about people who use services support staff, carers and partner agencies to deliver safe care and treatment? (This includes coordination between different electronic and paper-based systems and appropriate access for staff to records.)’” Source location 2017-0329-Response-by-Care-Quality-Commission
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 Have inspectors use two specific information-sharing questions when reviewing practice safety from November 2017.
Verbatim wording from the response “We have revised and improved the wording of our Key Lines of Enquiry and from November 2017 inspectors will be considering the following two specific questions when they are reviewing the safety of a practice, instead of one being a prompt supporting the other: ‘When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?’ and ‘How well do the systems that manage information about people who use services support staff, carers and partner agencies to deliver safe care and treatment? (This includes coordination between different electronic and paper-based systems and appropriate access for staff to records.)’” Source location 2017-0329-Response-by-Care-Quality-Commission
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 Welsh Clinical Portal access was considered sufficient for the GP to review the patient's A&E attendance outcome despite the discharge summary issue.
Verbatim wording from the response “All Primary and Secondary Care Doctors have access to the Welsh Clinical Portal. This allows them to access test, radiology and documentation for a patient wherever the patient receives cares in Wales, regardless of geographical or organisational boundaries. See attached printout from the NHS Wales Informatics Service website which provides further information. Mr Jacks' GP would have had access to this and would have been able to review the outcome of his attendance at the A & E Department at Bronglais General Hospital on 6 February 2017.” Source location 2017-0329-Response
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.