Recipient

Delamere Medical Practice

First report 11 Jan 2019•Latest report 11 Jan 2019

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: 0%
Concerns addressed: 0
Stated actions: 0

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.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Delamere Medical Practice linked to the concerns in each report. Select any concern, action or position to view the source wording.

11 Jan2019
Manchester South
Concerns raised7
1. Failure to document and justify the volume of tramadol prescribed despite recorded non-compliance and self-medication
2. Failure of the GP practice recording system to accurately distinguish repeat and acute prescriptions
3. Failure to explore alternatives to repeated painkiller prescribing for persistent back pain
1. Lack of continuity of care preventing a clinician from maintaining an overview of the patient and her health
2. Lack of detail in GP and ANP consultation notes
3. Failure to document the extent and issues considered during medication reviews
4. Medication reviews failing to provide a full overview of prescribed long-term medication
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

Jacqueline Marie Elliott · 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

Jacqueline Marie Elliott, who had a long-standing history of back pain, was found deceased at home on 9 August 2018. Post-mortem and toxicology findings identified reduced liver function and significant toxicity from a combination of drugs. Concerns included inaccurate prescription records, insufficient clinical notes and medication-review detail, prescribing of 100 tramadol tablets despite a recorded history of non-compliance and self-medication, and a lack of continuity of care.

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 Delamere Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to document and justify the volume of tramadol prescribed despite recorded non-compliance and self-medication
Wider context from the report
“4. There was a recorded history of non-compliance and deliberate self-medication of painkillers by Mrs Elliott. Despite that a GP immediately before her death in a telephone consultation prescribed her with 100 tramadol tablets whilst recording that she needed an urgent review. The rationale for prescribing this volume of medication was unclear from the notes; ”
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 Delamere Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure of the GP practice recording system to accurately distinguish repeat and acute prescriptions
Wider context from the report
“1. The GP practice computer recording system showed drugs that were clearly on repeat prescription as drugs that were acute prescriptions. As a result the inquest was told that the medication reviews carried out would not pick up on and would not review those prescriptions. The medication reviewer would not therefore have a full overview of her prescribed long term medication; ”
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 Delamere Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to explore alternatives to repeated painkiller prescribing for persistent back pain
Wider context from the report
“5. There was a lack of continuity of care. Mrs Elliott saw a variety of different locum GPs. This meant that no clinician had an overview of her and her health. As a result, painkillers were repeatedly prescribed and other potential ways of managing her persistent back pain were not explored. This led to a significant reliance by Mrs Elliott on painkillers to manage her on going back problems. The inquest was told that the lack of continuity of care was due to a national shortage of GPs and was a national not local issue. ”
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 Delamere Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Lack of continuity of care preventing a clinician from maintaining an overview of the patient and her health
Wider context from the report
“5. There was a lack of continuity of care. Mrs Elliott saw a variety of different locum GPs. This meant that no clinician had an overview of her and her health. As a result, painkillers were repeatedly prescribed and other potential ways of managing her persistent back pain were not explored. This led to a significant reliance by Mrs Elliott on painkillers to manage her on going back problems. The inquest was told that the lack of continuity of care was due to a national shortage of GPs and was a national not local issue. ”
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 Delamere Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Lack of detail in GP and ANP consultation notes
Wider context from the report
“2. The notes made by GPs and the ANP who had seen her/had telephone consultations lacked detail and so it was difficult to assess what information had been provided previously and what advice she had been given; ”
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 Delamere Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to document the extent and issues considered during medication reviews
Wider context from the report
“3. There was no detail provided in the notes at the inquest of the extent or issues considered during the medication reviews that were recorded as having taken place; ”
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 Delamere Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Medication reviews failing to provide a full overview of prescribed long-term medication
Wider context from the report
“1. The GP practice computer recording system showed drugs that were clearly on repeat prescription as drugs that were acute prescriptions. As a result the inquest was told that the medication reviews carried out would not pick up on and would not review those prescriptions. The medication reviewer would not therefore have a full overview of her prescribed long term medication; ”
Open source report

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 raised7

Failure to document and justify the volume of tramadol prescribed despite recorded non-compliance and self-medication

Failure of the GP practice recording system to accurately distinguish repeat and acute prescriptions

Failure to explore alternatives to repeated painkiller prescribing for persistent back pain

Lack of continuity of care preventing a clinician from maintaining an overview of the patient and her health

Lack of detail in GP and ANP consultation notes

Failure to document the extent and issues considered during medication reviews

Medication reviews failing to provide a full overview of prescribed long-term medication