15 Jan 2015 Judith Anne SAVILLE · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 4 Failure to implement the action plan arising from the Root Cause Analysis View source Failure to limit medication supplies for patients with a history of prescribed-medication overdose View source Lack of a computer-system warning for patients with a history of overdose View source Failure to audit the effectiveness of the action plan View source See 1 more concern
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Judith Anne SAVILLE · 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
Judith Anne Saville, who had a long history of agitated depression and previous psychiatric admissions and ECT treatment, was found deceased at home on 28 January 2014. The inquest concluded that she died from a Zopiclone and Paracetamol overdose and that she had taken her own life. Concerns included the quantity of medication prescribed, the need for warnings about a history of overdose in the practice’s computer system, and implementation and auditing of an action plan.
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× 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 Axminster Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to implement the action plan arising from the Root Cause Analysis
Wider context from the report “(2) For the attention of Melanie Walker
The Inquest heard evidence from ████████████████████ who had conducted a Root Cause Analysis into the circumstances of Mrs Saville’s death. A copy of that Report is attached.
████████ gave evidence that there were a number of lessons to be learned and that an action plan had been drafted .
At Inquest I expressed my concern that the action plan was implemented and its effectiveness subsequently audited.
” Open source report × 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 Axminster Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to limit medication supplies for patients with a history of prescribed-medication overdose
Wider context from the report “(1) For the attention of ████████
In his evidence ████████ told the Court that Mrs Saville’s death had been reviewed at a significant events meeting in his practice. I was told that it was felt he had prescribed too much medication, particularly as the person who had a past medical history that included overdoses of prescribed medication . ████████ said that there was now an increased awareness on the Practitioners not to prescribe so much medication in similar circumstances . He felt that a supply of no more than a week’s worth of medication would be appropriate .
████████ said that the system could be made more robust by introducing a warning on the firm’s computer system. This would assist Practitioners by drawing to their attention a past medical history of overdose. It was felt that this may particularly be of benefit to locum doctors who would not necessarily have the same recall of a patient as a partner in the practice.
” Open source report × 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 Axminster Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of a computer-system warning for patients with a history of overdose
Wider context from the report “(1) For the attention of ████████
In his evidence ████████ told the Court that Mrs Saville’s death had been reviewed at a significant events meeting in his practice. I was told that it was felt he had prescribed too much medication, particularly as the person who had a past medical history that included overdoses of prescribed medication. ████████ said that there was now an increased awareness on the Practitioners not to prescribe so much medication in similar circumstances. He felt that a supply of no more than a week’s worth of medication would be appropriate.
████████ said that the system could be made more robust by introducing a warning on the firm’s computer system . This would assist Practitioners by drawing to their attention a past medical history of overdose . It was felt that this may particularly be of benefit to locum doctors who would not necessarily have the same recall of a patient as a partner in the practice .
” Open source report × 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 Axminster Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to audit the effectiveness of the action plan
Wider context from the report “(2) For the attention of Melanie Walker
The Inquest heard evidence from ████████████████████ who had conducted a Root Cause Analysis into the circumstances of Mrs Saville’s death. A copy of that Report is attached.
████████ gave evidence that there were a number of lessons to be learned and that an action plan had been drafted.
At Inquest I expressed my concern that the action plan was implemented and its effectiveness subsequently audited .
” Open source report
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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 Restricting prescriptions cannot prevent patients from stockpiling regular medication or accessing other toxic medicines, including over-the-counter drugs.
Verbatim wording from the response “Our local pharmacists and dispensers do also flag to us when patients appear to be receiving medications earlier than would be expected. As you will understand however, restricting prescribed medications would not prevent patients who have chosen to “stockpile” regular medications from holding large numbers of any pill which we prescribe regularly. There are many medications which are much more toxic than zopiclone and of course many over the counter medications which would also be toxic in overdose.” Source location 2015-0011-Response-by-Axminster-Medical-Practice
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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 Existing computer prescribing prompts and pharmacist or dispenser alerts are considered sufficient safeguards for zopiclone prescribing.
Verbatim wording from the response “In the situation in which normally we prescribe Zopiclone, short courses of limited numbers of pills are advisable and our computer system automatically offers us this choice with a label which advises against repeat or regular use. There will inevitably be some patients for whom it has been decided that a regular prescription of one months supply is appropriate. In Mrs Saville’s particular circumstance we would not necessarily agree that ████████ prescribed too many zopiclone pills, although we sympathise with his comments. Viewing her prescribing records it appears that she was not prescribed on any single occasion more than a months supply at the dose ████████ had decided on. We would certainly all agree that in cases where there is a heightened risk of suicide we would endeavour to restrict all supplies of potentially toxic medication of any type.” Source location 2015-0011-Response-by-Axminster-Medical-Practice
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 practice does not agree that too many zopiclone pills were prescribed, as no single prescription exceeded one month’s supply.
Verbatim wording from the response “In the situation in which normally we prescribe Zopiclone, short courses of limited numbers of pills are advisable and our computer system automatically offers us this choice with a label which advises against repeat or regular use. There will inevitably be some patients for whom it has been decided that a regular prescription of one months supply is appropriate. In Mrs Saville’s particular circumstance we would not necessarily agree that ████████ prescribed too many zopiclone pills, although we sympathise with his comments. Viewing her prescribing records it appears that she was not prescribed on any single occasion more than a months supply at the dose ████████ had decided on. We would certainly all agree that in cases where there is a heightened risk of suicide we would endeavour to restrict all supplies of potentially toxic medication of any type.” Source location 2015-0011-Response-by-Axminster-Medical-Practice
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 A special flag for previous overdoses is considered problematic because it may be irrelevant, misleading, judgemental or offensive.
Verbatim wording from the response “To have a special flag which highlights that a patient has taken overdoses in the past would be problematic because this is not relevant information for many such people and significant numbers of patient have taken overdoses in the past but are not at increased risk of repeating any form of self-harm. Patients rightly expect that their medical records are both accurate and do not stress information which might in some way be viewed as judgemental and a special flag or message which is given more weight than any other part of their medical history might well be offensive to some.” Source location 2015-0011-Response-by-Axminster-Medical-Practice
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 Routine review of the accessible medical-record summary is considered sufficient to identify relevant previous overdoses during patient assessment.
Verbatim wording from the response “Your recommendations have lead us to consider the methods available to GPs in assessing whether a patient might have an increased risk of suicide. Mrs Saville’s medical records record clearly in the summary that she had taken two overdoses, one in 1994 after what is described as a marriage break-up and another in 2010. All the GP’s agreed that it would be a normal part of assessing a patient to look at the summary page which is clear and easily accessible. All the information contained therein would naturally be taken into account especially if it is relevant to the reason a patient is consulting.” Source location 2015-0011-Response-by-Axminster-Medical-Practice
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations