Recurring concern

Inadequate guidance for safe opioid prescribing

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First reported 31 Dec 2018•Latest report 12 Jun 2024

Definition

What this concern includes

Includes deficiencies in guidance, policies or standardised procedures specifically governing opioid prescribing, including discharge oramorph prescribing, long-term opioid prescribing, high-dose or multiple-analgesic prescribing, supply limits, monitoring, review and referral thresholds.

Not included

Excludes generic medication-prescribing failures where opioid prescribing is not the material concern.
Excludes opioid storage, administration, dispensing, access-control and post-prescribing follow-up failures unless the asserted deficiency is specifically in opioid-prescribing guidance.
Excludes guidance for non-opioid medicines or unrelated clinical conditions.
Excludes failures to follow clear opioid-prescribing guidance when the guidance itself is adequate.

Reports: 3
Individual concerns: 5
Date range: 2018–2024
Stated actions: 5

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Cwm Taf Morgannwg University Local Health Board1

National Institute for Health and Care Excellence1

Petroc Group Practice1

Concerns and responses across reports

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

12 Jun2024
Cornwall and Isles of Scilly
Concerns raised3
1. Lack of GP practice policy for co-prescription of opioids and benzodiazepines
2. Lack of GP practice policy for long-term opioid prescribing
3. Lack of practice policy requiring agreement of an opioid treatment strategy and end-of-treatment plan
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Develop a comprehensive practice policy for opioid prescribing.
  Stated by Petroc Group PracticeStated completed
2. Action
  Raise opioid prescribing as a significant event for practice-wide consideration.
  Stated by Petroc Group PracticeStated completed
3. Action
  Discuss the opioid prescribing policy and its application at the scheduled practice-wide meeting, then circulate the minutes and policy to staff.
  Stated by Petroc Group PracticeStated planned
AI-generated summary

Louise Helen Jones · 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

Louise Helen Jones was found deceased at home on 1 October 2023. The inquest recorded respiratory depression and opiate drug use, following an unintentional overdose involving morphine and bromazalam alongside other central nervous system depressant drugs. Concerns included the absence of an agreed opioid treatment and end-of-treatment plan, practice policies for long-term opioid prescribing and opioid–benzodiazepine co-prescribing, and warning flags after three months of morphine prescription.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of GP practice policy for co-prescription of opioids and benzodiazepines
Wider context from the report
“(4) There was no policy in place at the GP practice regarding co-prescription of opioids and benzodiazepines, to reflect the MHRA/CHM advice referred to in NICE guidance regarding the increased risk of respiratory depression and death. ”
Source location
Louise Helen Jones · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of GP practice policy for long-term opioid prescribing
Wider context from the report
“(2) There was no policy in place at the GP practice regarding long term (longer than 3 months) prescription of opioids. ”
Source location
Louise Helen Jones · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of practice policy requiring agreement of an opioid treatment strategy and end-of-treatment plan
Wider context from the report
“(1) There was no agreement with Louise before starting opioids, regarding a treatment strategy and plan for end of treatment as recommended by NICE. There was no practice policy requiring such an agreement. ”
Source location
Louise Helen Jones · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a comprehensive practice policy for opioid prescribing.

Verbatim wording from the response
“In response to the points raised in the PFD report, we have developed a comprehensive practice policy for opioid prescribing. We believe this policy addresses points 1 to 4 in the report.”

Source location
Response from Petroc Group
Page 1 · response
Published 25 June 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Raise opioid prescribing as a significant event for practice-wide consideration.

Verbatim wording from the response
“2. Significant Event Discussion: We have raised this as a significant event and will discuss it at our next practice-wide meeting, scheduled for the 19th of September. During this meeting, we will cover the new policy and how it pertains to our approach to new and ongoing prescriptions for opioids. Minutes and copies of the policy will be circulated afterwards and made available to all staff.”

Source location
Response from Petroc Group
Page 1 · response
Published 25 June 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Discuss the opioid prescribing policy and its application at the scheduled practice-wide meeting, then circulate the minutes and policy to staff.

Verbatim wording from the response
“2. Significant Event Discussion: We have raised this as a significant event and will discuss it at our next practice-wide meeting, scheduled for the 19th of September. During this meeting, we will cover the new policy and how it pertains to our approach to new and ongoing prescriptions for opioids. Minutes and copies of the policy will be circulated afterwards and made available to all staff.”

Source location
Response from Petroc Group
Page 1 · response
Published 25 June 2024
Open published response
18 Sep2019
Bedfordshire and Luton
Concerns raised1
1. Failure of the BNF to provide caution and monitoring guidance for simultaneous amitriptyline and oxycodone prescribing
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Not all opioid–tricyclic combinations should be stopped because low-dose combinations may be clinically appropriate; risks should be reviewed individually.
  Stated by NHS Central East Integrated Care BoardDisputes the concern
AI-generated summary

Graham Martin SAFFERY · 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 Martin SAFFERY was found deceased at home on 19 June 2018 after taking prescribed oxycodone and amitriptyline. The inquest conclusion stated that the combination carried a risk of sudden death and that his prescription remained unchanged despite signs of over-sedation. A substantive concern was that the BNF did not appear to provide the caution and monitoring advice given by other pharmacological guidance for simultaneous prescribing of these medicines.

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 of the BNF to provide caution and monitoring guidance for simultaneous amitriptyline and oxycodone prescribing
Wider context from the report
“Although other pharmacological guidance such as Medscape Drug Interaction Checker and Stockley’s Interaction Checker recommend the need for both caution and monitoring when prescribing amitriptyline and oxycodone simultaneously, such advice does not appear to be provided by the BNF which is regularly consulted and relied upon by GPs. ”
Source location
Graham Martin SAFFERY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Not all opioid–tricyclic combinations should be stopped because low-dose combinations may be clinically appropriate; risks should be reviewed individually.

Verbatim wording from the response
“We are not expecting that all patients identified on a combination of an opioid and tricyclic antidepressant will have their medication stopped, but the risk associated with the level of sedation will be reviewed and action can then be taken as appropriate. The use of low dose opioids with low dose amitriptyline may be clinically appropriate.”

Source location
2019-0301-Response-by-Bedfordshire-CCG
Page 3 · response
Published 5 November 2019
Open published response
31 Dec2018
South Wales Central
Concerns raised1
1. Lack of formal guidance for prescribing oramorph to discharging patients
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Develop a corrective Action Plan for Improvement addressing the concerns identified in the Regulation 28 report.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated completed
2. Action
  Implement a Standard Operating Procedure governing the appropriate use of oral opioid medication for acute pain.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated completed
AI-generated summary

Janice Mary Davies · 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

Janice Mary Davies fell out of bed at home on 19 April 2018, sustaining fractured ribs, and was treated with oramorph before being discharged. She died at home in the early hours of 21 April 2018; the medical cause included morphine toxicity, bilateral rib fractures, chronic obstructive pulmonary disease and chronic kidney disease. Concerns included missing post-dose observations and pain-score documentation, and a lack of formal guidance for prescribing oramorph to patients being discharged.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of formal guidance for prescribing oramorph to discharging patients
Wider context from the report
“(3) Most significantly, there appeared, on the evidence, to be an absence of formal guidance or instruction-- written or otherwise to clinicians in the Accident & Emergency Department regarding the prescribing of oramorph to discharging patients. This would appear then to give rise to potential inconsistencies in the prescribing of oramorph to discharging patients. Not only in terms of prescribed dosages, but also in respect of the extent of the supply. The deceased was prescribed 40 mls per day & given a supply lasting two weeks. ████████ evidence was that in the absence of clear evidence as to the deceased's tolerance to morphine, he would be uncomfortable with this dosage & supply. His evidence was that a prescription of 20 mls per day, & a supply for 5 days (then review by GP if symptoms persisted/to assess the patient's reaction to the oramorph) was more appropriate in the circumstances. ”
Source location
Janice Mary Davies · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a corrective Action Plan for Improvement addressing the concerns identified in the Regulation 28 report.

Verbatim wording from the response
“1. Action taken to plan and monitor improvements A corrective Action Plan for Improvement has been developed which reflects the concerns identified within the Regulation 28 Report.”

Source location
2018-0409-Response-by-University-Health-Board
Page 1 · response
Published 31 December 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement a Standard Operating Procedure governing the appropriate use of oral opioid medication for acute pain.

Verbatim wording from the response
“2) A Standard Operating Procedure has been implemented to advise on the appropriate use of oral opioid medication in acute pain. A copy is attached.”

Source location
2018-0409-Response-by-University-Health-Board
Page 1 · response
Published 31 December 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Lack of GP practice policy for co-prescription of opioids and benzodiazepines

Lack of GP practice policy for long-term opioid prescribing

Lack of practice policy requiring agreement of an opioid treatment strategy and end-of-treatment plan

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure of the BNF to provide caution and monitoring guidance for simultaneous amitriptyline and oxycodone prescribing

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

Concerns raised1

Lack of formal guidance for prescribing oramorph to discharging patients

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Actions described in response 3

Respondent positions 1

Actions described in response 2