Dinnington Group Practice

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First report 29 Mar 2017•Latest report 29 Mar 2017

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
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

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

29 Mar2017
South Yorkshire (Eastern)
Concerns raised8
1. Lack of medical review during the initial phase of methadone treatment
2. Provision of a 7-day methadone supply to a methadone-naive patient
3. Absence of systems to audit the effectiveness and reliability of the pre-alert system
1. Failure to conduct a face-to-face consultation before prescribing methadone
2. Lack of detail regarding drugs taken, usage frequency and dependence before methadone prescribing
3. Lack of staff knowledge and training for reliable actioning of pre-alert requests
4. Absence of assessment of psychological issues before methadone prescribing
5. Failure to convey all relevant clinical information
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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

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 raised8

Lack of medical review during the initial phase of methadone treatment

Provision of a 7-day methadone supply to a methadone-naive patient

Absence of systems to audit the effectiveness and reliability of the pre-alert system

Failure to conduct a face-to-face consultation before prescribing methadone

Lack of detail regarding drugs taken, usage frequency and dependence before methadone prescribing

Lack of staff knowledge and training for reliable actioning of pre-alert requests

Absence of assessment of psychological issues before methadone prescribing

Failure to convey all relevant clinical information