Addison House Surgery

Wider context from the report

“Evidence was received from two GP Partners at Mr Smith’s GP Practice. Both GPs confirmed that at the time of Mr Smith’s involvement with the Practice continuing up to and including the date of the inquest, there continued to be no system, policy or process in place, to ensure that vulnerable patients with a history of addiction and/or self-harm and/or suicidal ideation and/or prescription medication overdose received or receive appropriate medication reviews to consider the frequency and volume of repeat prescribed medication. It was conceded, accordingly, that there was - and remained - no policy or procedure in place to mitigate the clear risk involved in GPs prescribing unnecessarily excessive quantities of (potentially dangerous) prescription medication (at inappropriate frequency) to a clearly vulnerable cohort of patients, and therefore no policy or procedure is in place to minimise the danger of stockpiling of such medications and the concomitant risk of potentially fatal, (advertent or inadvertent), misuse of such medication. ”