Concerns raised 5 Lack of a formal medication review process for long-term medication prescribing View source Failure to listen to family concerns about changed patient behaviour View source Lack of team meetings to discuss challenging patients View source Failure to safely assess morphine prescribing alongside high-dose painkillers and alcohol dependence View source Lack of a timely proactive approach to involving community mental health services View source See 2 more concerns
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. 2
Action
Develop structured criteria and a protocol for identifying complex patients who would benefit from discussion at clinical meetings.
View source
Action
Consider and initiate independent medication reviews by asking an uninvolved doctor to review complex patients’ medication when appropriate.
View source
×
AI-generated summary
Pauline Meredith · 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
Pauline Meredith, aged 42, was found dead in her flat on 30 August 2013. Her death was attributed to mixed drug toxicity, including a fatal level of morphine, excessive levels of tramadol and propranolol, and alcohol. Concerns included the amount and review of prescribed medication, the addition of morphine alongside existing medication and alcohol dependence, the response to family concerns, the absence of team meetings, and delays in involving community mental health services.
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 Browning Street Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal medication review process for long-term medication prescribing
Wider context from the report “(1) The amount of medication prescribed to the deceased over many years with no formal medication review process .
” 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 Browning Street Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to listen to family concerns about changed patient behaviour
Wider context from the report “(3) The family’s perceived reluctance by the GP to listen to the concerns expressed by them with regards to the changed behaviour of the patient following the addition of morphine .
” 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 Browning Street Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of team meetings to discuss challenging patients
Wider context from the report “(4) The lack of any team meetings with colleagues affording an opportunity to discuss challenging patients with colleagues .
” 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 Browning Street Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to safely assess morphine prescribing alongside high-dose painkillers and alcohol dependence
Wider context from the report “(2) The more recent addition of morphine to the prescription for a patient already on a high dose of pain killers and with alcohol dependence
” 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 Browning Street Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of a timely proactive approach to involving community mental health services
Wider context from the report “(5) The lack of a more timely proactive approach with regards to involving community mental health services .
” 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 structured criteria and a protocol for identifying complex patients who would benefit from discussion at clinical meetings.
Verbatim wording from the response “2) The practice will endeavour in the future to identify complex patients who might benefit from discussion at clinical meetings. The practice is currently considering how to select patients for these” Source location 2014-0011-Response-by-Browning-Street-Surgery
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 Consider and initiate independent medication reviews by asking an uninvolved doctor to review complex patients’ medication when appropriate.
Verbatim wording from the response “3) Miss Meredith had seen 3 other doctors and the nurse practitioner in previous 8 months before her death. Having reflected on this case, I recognise that it can often be useful to have another clinician with a fresh pair of eyes looking at patients with chronic problems. The practice will consider whether there are circumstances where the medication reviews are best carried out by another doctor who is not so involved with the case. This would be actioned by the regular doctor asking for a medication review by a colleague who was not involved in management of the case. This is to be initiated from now.” Source location 2014-0011-Response-by-Browning-Street-Surgery
Open published response
×
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 Morphine was considered appropriate because pain was significant, alternatives had failed, alcohol intake had reduced, and prescribing was regularly reviewed.
Verbatim wording from the response “In response to her request for additional analgesia in February 2013, options were limited. For pain relief, she was already taking tramadol 50mg 2 tablets four times daily (maximum dose) plus paracetamol 500mg 2 tablets four times daily (maximum dose) and diclofenac 50mg three times daily (maximal usual dose). I was reluctant to prescribe co-codamol or codeine or dihydrocodeine. These had previously been prescribed with little effect on her pain. She was already on a strong anti-inflammatory painkiller (diclofenac) and so there was little value in changing to an alternative anti-inflammatory. As Miss Meredith’s pain appeared significant, I decided to prescribe MST (slow release morphine sulphate tablets) 1 tablet twice daily at the lowest dose possible, 10mg. The treatment plan initially was to prescribe this for one week and then review whilst she regained control of her pain.” Source location 2014-0011-Response-by-Browning-Street-Surgery
Open published response
×
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 computerised reviews, weekly prescriptions and consultations were considered sufficient to monitor and control medication access.
Verbatim wording from the response “I would wish to reassure you that there is indeed a formal medication review process used at the practice. The medication review system is computer based. The computer automatically initiates a demand for review of medication for each patient who has repeat medications. This is usually annually but can occur more frequently depending on the monitoring requirements stipulated by the prescribing doctor. The computer also places limits on the number of repeats that can be issued without re-authorisation of the repeat medication by a doctor. The review of repeat medication is usually based on clinical information contained in annual health checks or from consultations at the practice or from a dedicated review of repeat medication with the patient.” Source location 2014-0011-Response-by-Browning-Street-Surgery
Open published response
×
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 Earlier mental-health referral or compulsory admission was not considered necessary while the patient refused referral, retained capacity and was not sufficiently disturbed.
Verbatim wording from the response “Summary: Miss Meredith had been much more stable since a difficult period in 2009–2010 which was associated with overdoses and self-harm during which she had never engaged with mental health support. In 2013, she was dealing with significant levels of family stress and had developed paranoid ideas about her neighbours. Otherwise her mental state although anxious was certainly not psychotic and she continued to function relatively normally. Miss Meredith refused to accept a referral to mental health services on at least 3 times between May and July 2013 when I suggested it. There were no time when she was so disturbed that she could have been sectioned under the Mental Health Act. She maintained capacity and so had to consent to any referral being made.” Source location 2014-0011-Response-by-Browning-Street-Surgery
Open published response
×
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 practice meeting was not considered necessary because the patient appeared relatively stable and was receiving frequent support and supervision.
Verbatim wording from the response “4. The lack of team meetings to discuss challenging patients:
It is likely that I would have discussed Pauline and her anxiety and paranoid thinking with my General Practice colleagues in an informal way, as this often occurs in the course of General Practice when challenging problems are posed by patients, but I cannot recollect when this may have occurred. Informal discussions are not recorded in the notes.” Source location 2014-0011-Response-by-Browning-Street-Surgery
Open published response
×
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 paranoid thoughts were considered unrelated to morphine and more likely associated with stress and previous similar episodes.
Verbatim wording from the response “With regard to ████████ concern about the paranoia being related to the morphine, I did not consider this to be likely. Miss Meredith’s thoughts seem to be a localised paranoia as otherwise her mental state seemed appropriate, according to the information that I had from Miss Meredith and her family. My impression was that it would be very unusual for Morphine to trigger paranoia and her paranoid thoughts were more likely to be a response to stressful situations.
Morphine is not usually associated with paranoia or delusions, although can be associated with hallucinations, confusion and agitation. I additionally considered that Miss Meredith’s paranoid thoughts were similar to her previous episodes when she reported paranoid feelings between 2003 and 2006. At that time she had thought that she was being followed by special branch or inspectors from the benefits agency.” Source location 2014-0011-Response-by-Browning-Street-Surgery
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations