Alvaston Medical Centre

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First report 20 Dec 2021•Latest report 20 Dec 2021

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
5

Described in responses

Concerns and recipient responses

Statements from Alvaston Medical Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Derby and Derbyshire

    AI-generated summary

    Maria Susan McGAURAN · 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

    Maria Susan McGAURAN had been prescribed codeine and citalopram and died at home on 28 November 2018 due to the combined toxicity of those medications. Concerns were raised that she had hoarded and taken medication erratically, but the Surgery did not undertake a requested medication review or consider alternative pain management earlier.

    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. The report was sent to Alvaston Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake a medication review in response to known excessive, hoarded and erratic medication use

    Wider context from the report

    “Ms McGauran had over several years been known to take excessive amounts of her codeine prescription medication. She had a history of hoarding medication and taking her medication erratically. Her family raised concerns with the Surgery as to her reliance on several differing medications. They requested that a review of her medications be undertaken. No such review was undertaken. The Surgery could have considered alternative pain management aids at an earlier stage (such as the Fentanyl patches considered only 1 month before death i.e. in October 2018) so as to prevent the risks of overdose. ”
    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

    Prevent high-risk scheduled drugs from forming part of repeat prescriptions wherever possible.

    Verbatim wording from the response

    “3. Alvaston has also made it good practice, to ensure wherever possible, any high risk scheduled drugs do not form part of the repeat prescription. Furthermore, we have a robust system in place to ensure the prescribing of medications is not automatically ordered too far in advance of their due date. This reduces the risk of any patient's 'stock-piling' medication. This is an ongoing project that is constantly being reviewed and refined, and we continue to further assess which areas or medications would benefit from additional surveillance during the prescribing and issuing of the prescription.”

    Source location

    2022-0098-Response-from-Alvaston-Medical-Centre_Published
    Page 1 · response
    Published 26 April 2022

    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

    Conduct structured, holistic medication reviews covering compliance, understanding, social history, lifestyle and medication changes.

    Verbatim wording from the response

    “1. Taking advantage of the expanding job roles within primary care, over the period January to February 2021, Alvaston Medical Centre recruited two clinical pharmacists to undergo patient medication reviews. The clinical pharmacist's area of professional expertise means they are ideally suited to conducting structured medication reviews of patients – including extensive knowledge of controlled drugs. As part of the medication review, they explore the patient’s compliance and understanding of their medication, along with addressing other concerns within their remit.”

    Source location

    2022-0098-Response-from-Alvaston-Medical-Centre_Published
    Page 1 · response
    Published 26 April 2022

    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

    Prevent prescriptions from being ordered automatically too far in advance of their due dates.

    Verbatim wording from the response

    “3. Alvaston has also made it good practice, to ensure wherever possible, any high risk scheduled drugs do not form part of the repeat prescription. Furthermore, we have a robust system in place to ensure the prescribing of medications is not automatically ordered too far in advance of their due date. This reduces the risk of any patient's 'stock-piling' medication. This is an ongoing project that is constantly being reviewed and refined, and we continue to further assess which areas or medications would benefit from additional surveillance during the prescribing and issuing of the prescription.”

    Source location

    2022-0098-Response-from-Alvaston-Medical-Centre_Published
    Page 1 · response
    Published 26 April 2022

    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

    Continue assessing medications and prescribing areas that would benefit from additional surveillance.

    Verbatim wording from the response

    “3. Alvaston has also made it good practice, to ensure wherever possible, any high risk scheduled drugs do not form part of the repeat prescription. Furthermore, we have a robust system in place to ensure the prescribing of medications is not automatically ordered too far in advance of their due date. This reduces the risk of any patient's 'stock-piling' medication. This is an ongoing project that is constantly being reviewed and refined, and we continue to further assess which areas or medications would benefit from additional surveillance during the prescribing and issuing of the prescription.”

    Source location

    2022-0098-Response-from-Alvaston-Medical-Centre_Published
    Page 1 · response
    Published 26 April 2022

    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

    Recruit two clinical pharmacists to support patient medication reviews.

    Verbatim wording from the response

    “1. Taking advantage of the expanding job roles within primary care, over the period January to February 2021, Alvaston Medical Centre recruited two clinical pharmacists to undergo patient medication reviews. The clinical pharmacist's area of professional expertise means they are ideally suited to conducting structured medication reviews of patients – including extensive knowledge of controlled drugs. As part of the medication review, they explore the patient’s compliance and understanding of their medication, along with addressing other concerns within their remit.”

    Source location

    2022-0098-Response-from-Alvaston-Medical-Centre_Published
    Page 1 · response
    Published 26 April 2022

    Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026