Recipient

Alvaston Medical Centre

First report 20 Dec 2021•Latest report 20 Dec 2021

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 1
Stated actions: 5

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

5stated actions described

Topic comparisons are not available in the current evidence snapshot.

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.

20 Dec2021
Derby and Derbyshire
Concerns raised1
1. Failure to undertake a medication review in response to known excessive, hoarded and erratic medication use
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Prevent high-risk scheduled drugs from forming part of repeat prescriptions wherever possible.
  Stated completed
2. Action
  Conduct structured, holistic medication reviews covering compliance, understanding, social history, lifestyle and medication changes.
  Stated planned
3. Action
  Prevent prescriptions from being ordered automatically too far in advance of their due dates.
  Stated completed
1. Action
  Continue assessing medications and prescribing areas that would benefit from additional surveillance.
  Stated in progress
2. Action
  Recruit two clinical pharmacists to support patient medication reviews.
  Stated completed
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

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

Reports, concerns and published responses

Reports over time

Concerns raised1

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

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.5

Actions described in response 5