16 Feb 2017 Thomas Josef Green · Prevention of Future Deaths report Manchester South
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Concerns raised 6 Failure to consider and action referrals to Adult General Psychiatry View source Lack of commissioned services for complex PTSD and complex presentations View source Insufficient detail in GP referral documentation to identify case complexity View source Lack of treatment plans addressing complex PTSD View source Inappropriate referral of complex PTSD presentations to Healthy Minds View source Lack of psychiatric follow-up after hospital discharge View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Thomas Josef Green · 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
Thomas Josef Green died at home on 10 June 2016; the medical cause of death was asphyxiation secondary to hanging, and the inquest concluded that he had taken his own life. The principal concerns related to unclear or unactioned psychiatric referral, lack of psychiatric follow-up and treatment for complex PTSD after discharge, referral to an unsuitable service, and a commissioning gap for complex PTSD 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 Churchgate Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and action referrals to Adult General Psychiatry
Wider context from the report “1. It was unclear why a referral was made to Adult General Psychiatry whilst Mr Green remained an inpatient, there was no evidence that this referral was ever considered or actioned .
” 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 Churchgate Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of commissioned services for complex PTSD and complex presentations
Wider context from the report “5. The Court heard evidence that there is a commissioning gap for the provision of services for Complex PTSD and complex presentations such as that of Mr Green.
” 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 Churchgate Surgery; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail in GP referral documentation to identify case complexity
Wider context from the report “4. The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted.
” 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 Churchgate Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of treatment plans addressing complex PTSD
Wider context from the report “2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD .
” 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 Churchgate Surgery; that does not assign responsibility.
PFD Monitor interpretation Inappropriate referral of complex PTSD presentations to Healthy Minds
Wider context from the report “3. When a referral was made this was made to Healthy Minds. The Court heard evidence how this was not a case which was suitable for Healthy Minds as it was complex and involved potentially complex PTSD .
” 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 Churchgate Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of psychiatric follow-up after hospital discharge
Wider context from the report “2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD.
” Open source report
19 Jan 2016 Irene Anne Pearson · Prevention of Future Deaths report Manchester South
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Concerns raised 7 Failure to define the terms “prolonged” and “hot” in the hot-bath warning View source Failure to reconcile prescribed opiate patches with the patient’s actual possession View source Failure to maintain clear and sufficiently detailed electronic clinical notes View source Failure to provide a full report of the patient’s care View source Provision of potentially dangerous bath-removal advice for exhausted Matrifen patches View source Failure to prominently communicate the danger of taking a hot bath whilst wearing the patch View source Lack of liaison with the GP Practice over regulation of additional opiate pain-control View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Irene Anne Pearson · 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 Anne Pearson had terminal colon cancer that had spread to other organs and was receiving palliative Matrifen patches. On 19 July 2015, she was found dead in a hot bath at home, apparently still wearing the patch; the stated medical cause of death included opiate toxicity. Concerns included warnings about hot baths and patch removal, advice and communication about opiate medication, unclear prescribing records, and the adequacy of information supplied by the GP practice to the Coroner.
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 Churchgate Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to define the terms “prolonged” and “hot” in the hot-bath warning
Wider context from the report “2. Even when the said warning phrase is reached in the leaflet, it then refers to “a prolonged hot bath” without in any way defining the words “prolonged” or “hot”. These terms are easily open to subjective interpretation, which may lead to an unsafe usage environment. (Takeda UK)
” 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 Churchgate Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to reconcile prescribed opiate patches with the patient’s actual possession
Wider context from the report “5. The GP Practice’s electronic notes of the attendances upon the patient were unclear and there appeared to be discrepancies between what was noted as prescribed by way of opiate patches, and what the patient actually had in her possession. The notes were on occasions ‘scanty’ in detail and the doctor giving evidence accepted this and told me that this was because they, as doctors, are limited to ten-minute appointments and they do not always have time properly to record their notes. (Churchgate Surgery)
” 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 Churchgate Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain clear and sufficiently detailed electronic clinical notes
Wider context from the report “5. The GP Practice’s electronic notes of the attendances upon the patient were unclear and there appeared to be discrepancies between what was noted as prescribed by way of opiate patches, and what the patient actually had in her possession. The notes were on occasions ‘scanty’ in detail and the doctor giving evidence accepted this and told me that this was because they, as doctors, are limited to ten-minute appointments and they do not always have time properly to record their notes. (Churchgate Surgery)
” 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 Churchgate Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a full report of the patient’s care
Wider context from the report “6. When HM Coroner asks for a full report of the care of the patient from the General Practitioner, it is insufficient (as in this case), for the practice simply to photocopy part of the patient’s records. (Churchgate Surgery)
” 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 Churchgate Surgery; that does not assign responsibility.
PFD Monitor interpretation Provision of potentially dangerous bath-removal advice for exhausted Matrifen patches
Wider context from the report “3. I heard evidence that the Macmillan Nurses had advised the deceased to take a bath when preparing to remove the ‘exhausted’ patch so as to aid removal. The toxicologist point out that even when due for changing the patch contains (and therefore can release) a very considerable level of the drug. The advice to use this method of removal would therefore be inherently potentially dangerous. (Macmillan Cancer Care)
” 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 Churchgate Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to prominently communicate the danger of taking a hot bath whilst wearing the patch
Wider context from the report “1. The package leaflet of advice on the use of Matrifen is very extensive running to several pages of closely printed words. It is not until half way down the eighth page (and then contained in the middle of a 4th bullet point) that there is reference to the danger of taking a hot bath whilst wearing the patch. The Forensic Consultant Toxicologist gave evidence to me that heating of the body will cause an onrush of the delivery of the drug. (Takeda UK)
” 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 Churchgate Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of liaison with the GP Practice over regulation of additional opiate pain-control
Wider context from the report “4. I was told that the Macmillan Nurses will prescribe additional opiate pain-control, but there seemed little or no liaison with the GP Practice as to the regulation of this. (Macmillan Cancer Care)
” 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