CareFlow Medicines Management Limited

Private and voluntary organisations · Company

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First report 28 Feb 2020•Latest report 28 Feb 2020

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
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from CareFlow Medicines Management Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Manchester West

    AI-generated summary

    Irene Whittingham · 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

    Irene Whittingham died at The Royal Bolton Hospital on 31 July 2019 from the toxic effects of a Vitamin D overdose. An incorrect discharge prescription recorded Vitamin D as twice daily, and no monitoring advice was provided while she was taking high doses in the community. Concerns included conflicting guidance on blood-level monitoring and software dropdown options that permitted a potentially unsafe dosage.

    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 CareFlow Medicines Management Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Conflicting guidance on timing of Vitamin D and Calcium blood level monitoring

    Wider context from the report

    “1. Conflicting guidance is provided to treating clinicians as to when Vitamin D and Calcium blood level monitoring should be undertaken especially in patients who are given higher (loading) doses of Vitamin D, which exceeds the recommended national guidelines. The Consultant in Acute Adult Medicine gave evidence that the expected blood level monitoring to have taken place within 4 weeks of the loaded Vitamin D commencing, whereas the Endocrinologist, gave evidence that he expected the blood level monitoring to take place around the 3 month period elapsed the course of medication had been completed. In any event, no advice or instructions were issued to the deceased GP, regarding any requirement to monitor the deceased blood levels whilst she was in the community and taking high levels of Vitamin D which exceeded national guidelines. ”
    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 CareFlow Medicines Management Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of prescribing software dropdown controls to prevent selection of excessive twice-daily loading doses

    Wider context from the report

    “3. The WellSky and EMIS Software, had a confusing user drop down menu option, which allowed the user to click on a twice daily dose despite the loaded dosage, exceeding national guidelines. ”
    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 CareFlow Medicines Management Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide community GPs with instructions on blood level monitoring during high-dose Vitamin D treatment

    Wider context from the report

    “1. Conflicting guidance is provided to treating clinicians as to when Vitamin D and Calcium blood level monitoring should be undertaken especially in patients who are given higher (loading) doses of Vitamin D, which exceeds the recommended national guidelines. The Consultant in Acute Adult Medicine gave evidence that the expected blood level monitoring to have taken place within 4 weeks of the loaded Vitamin D commencing, whereas the Endocrinologist, gave evidence that he expected the blood level monitoring to take place around the 3 month period elapsed the course of medication had been completed. In any event, no advice or instructions were issued to the deceased GP, regarding any requirement to monitor the deceased blood levels whilst she was in the community and taking high levels of Vitamin D which exceeded national guidelines. ”
    Open source report
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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