Concerns raised 8 Lack of medical review during the initial phase of methadone treatment View source Provision of a 7-day methadone supply to a methadone-naive patient View source Absence of systems to audit the effectiveness and reliability of the pre-alert system View source Failure to conduct a face-to-face consultation before prescribing methadone View source Lack of detail regarding drugs taken, usage frequency and dependence before methadone prescribing View source Lack of staff knowledge and training for reliable actioning of pre-alert requests View source Absence of assessment of psychological issues before methadone prescribing View source Failure to convey all relevant clinical information View source See 5 more concerns
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AI-generated summary
Lyndsey Holt · 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
Lyndsey Holt, who was 37 weeks pregnant, collapsed after a gastric ulcer perforated and caused catastrophic bleeding. She died the following morning after emergency surgery and resuscitation; concerns included the telephone prescribing of methadone without sufficient information, assessment, or early medical review, and the provision of a seven-day supply to a methadone-naïve patient.
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 Dinnington Group Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of medical review during the initial phase of methadone treatment
Wider context from the report “The circumstances in which the methadone was prescribed namely:
(1) Doing so over the telephone with no face to face consultation.
(2) Consequent lack of detail regarding:
2.1 the drugs being taken by Miss Holt
2.2 the frequency with which they were being taken
2.3 the degree if any, of her dependence
2.4 absence of assessment of any psychological issues
(3) Providing a methadone naïve patient with a 7 day supply.
(4) Lack of medical review during the initial phase.
” 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 Dinnington Group Practice; that does not assign responsibility.
PFD Monitor interpretation Provision of a 7-day methadone supply to a methadone-naive patient
Wider context from the report “The circumstances in which the methadone was prescribed namely:
(1) Doing so over the telephone with no face to face consultation.
(2) Consequent lack of detail regarding:
2.1 the drugs being taken by Miss Holt
2.2 the frequency with which they were being taken
2.3 the degree if any, of her dependence
2.4 absence of assessment of any psychological issues
(3) Providing a methadone naïve patient with a 7 day supply.
(4) Lack of medical review during the initial phase.
” 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 Dinnington Group Practice; that does not assign responsibility.
PFD Monitor interpretation Absence of systems to audit the effectiveness and reliability of the pre-alert system
Wider context from the report “I have concerns regarding the reliability of the pre-alert system, particularly where Control have responsibility for activating such an alert and passing on of relevant information, as follows:
(1) Absence of systems to audit the effectiveness and reliability of the pre-alert system.
(2) A lack of knowledge/training of staff in Control to equip them with the skills to undertake reliable actioning of pre-alert requests, the importance of doing and conveyance of all relevant clinical information.
” 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 Dinnington Group Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a face-to-face consultation before prescribing methadone
Wider context from the report “The circumstances in which the methadone was prescribed namely:
(1) Doing so over the telephone with no face to face consultation.
(2) Consequent lack of detail regarding:
2.1 the drugs being taken by Miss Holt
2.2 the frequency with which they were being taken
2.3 the degree if any, of her dependence
2.4 absence of assessment of any psychological issues
(3) Providing a methadone naïve patient with a 7 day supply.
(4) Lack of medical review during the initial phase.
” 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 Dinnington Group Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of detail regarding drugs taken, usage frequency and dependence before methadone prescribing
Wider context from the report “The circumstances in which the methadone was prescribed namely:
(1) Doing so over the telephone with no face to face consultation.
(2) Consequent lack of detail regarding:
2.1 the drugs being taken by Miss Holt
2.2 the frequency with which they were being taken
2.3 the degree if any, of her dependence
2.4 absence of assessment of any psychological issues
(3) Providing a methadone naïve patient with a 7 day supply.
(4) Lack of medical review during the initial phase.
” 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 Dinnington Group Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge and training for reliable actioning of pre-alert requests
Wider context from the report “I have concerns regarding the reliability of the pre-alert system, particularly where Control have responsibility for activating such an alert and passing on of relevant information, as follows:
(1) Absence of systems to audit the effectiveness and reliability of the pre-alert system.
(2) A lack of knowledge/training of staff in Control to equip them with the skills to undertake reliable actioning of pre-alert requests , the importance of doing and conveyance of all relevant clinical information.
” 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 Dinnington Group Practice; that does not assign responsibility.
PFD Monitor interpretation Absence of assessment of psychological issues before methadone prescribing
Wider context from the report “The circumstances in which the methadone was prescribed namely:
(1) Doing so over the telephone with no face to face consultation.
(2) Consequent lack of detail regarding:
2.1 the drugs being taken by Miss Holt
2.2 the frequency with which they were being taken
2.3 the degree if any, of her dependence
2.4 absence of assessment of any psychological issues
(3) Providing a methadone naïve patient with a 7 day supply.
(4) Lack of medical review during the initial phase.
” 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 Dinnington Group Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to convey all relevant clinical information
Wider context from the report “I have concerns regarding the reliability of the pre-alert system, particularly where Control have responsibility for activating such an alert and passing on of relevant information, as follows:
(1) Absence of systems to audit the effectiveness and reliability of the pre-alert system.
(2) A lack of knowledge/training of staff in Control to equip them with the skills to undertake reliable actioning of pre-alert requests, the importance of doing and conveyance of all relevant clinical information .
” 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