Recipient

Donneybrook Medical Centre

First report 17 Jun 2022•Latest report 17 Jun 2022

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: 100%
Concerns addressed: 2
Stated actions: 6

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.

100%published responses found

6stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

17 Jun2022
Manchester South
Concerns raised4
1. Inadequate specialist input for patients prescribed multiple analgesics on repeat prescription
2. Failure of GP practices with significant numbers of patients with complex analgesia regimes to engage practice pharmacists
3. Lack of systematic review of patients receiving repeat prescriptions of multiple analgesics
1. Failure to formulate individual plans for patients receiving repeat prescriptions of multiple analgesics
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Maintain a safety-netting system recording review dates and run monthly searches to identify new patients requiring inclusion.
  Stated completed
2. Action
  Use medicines-optimisation support to identify, categorise and prioritise patients receiving repeat prescriptions for multiple analgesics.
  Stated completed
3. Action
  Employ locum agency staff while pharmacist recruitment is ongoing.
  Stated completed
1. Action
  Limit prescription durations according to risk category and automatically arrange GP review when prescriptions become due.
  Stated planned
2. Action
  Recruit a pharmacist to support the medicines-management work.
  Stated planned
3. Action
  Review patients on the red, amber and green priority lists, including checking previous reviews and recording required follow-up dates.
  Stated in progress
AI-generated summary

Amanda Hesketh · 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

Amanda Hesketh, who had a complex health history and was prescribed multiple analgesic medicines, became unresponsive in the Emergency Department after presenting with diarrhoea and vomiting and could not be resuscitated. The report identified concerns about the lack of systematic reviews and individual plans for patients receiving multiple analgesics, limited specialist pain-clinic input, and inconsistent use of practice pharmacists.

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 Donneybrook Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Inadequate specialist input for patients prescribed multiple analgesics on repeat prescription
Wider context from the report
“The court heard evidence from a General Practitioner as to difficulties patients encounter in accessing services from specialist pain clinics with lengthy waiting lists often being experienced. It is a matter of concern that patients being prescribed multiple analgesics continue to receive such medicines on repeat prescription with often with little or no specialist input; ”
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 Donneybrook Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure of GP practices with significant numbers of patients with complex analgesia regimes to engage practice pharmacists
Wider context from the report
“It is a matter of concern that GP practices who have a significant number of patients with complex analgesia regimes do not universally engage practice pharmacists to complement the knowledge of doctors and enhance the advice provided to patients. ”
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 Donneybrook Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Lack of systematic review of patients receiving repeat prescriptions of multiple analgesics
Wider context from the report
“Notwithstanding the actions the practice has taken in response to Mrs Hesketh’s death, it is a matter of concern the partnership has yet to undertake or commission a systematic review of all patients receiving repeat prescriptions of multiple analgesics and formulate individual plans for each such patient; ”
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 Donneybrook Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to formulate individual plans for patients receiving repeat prescriptions of multiple analgesics
Wider context from the report
“Notwithstanding the actions the practice has taken in response to Mrs Hesketh’s death, it is a matter of concern the partnership has yet to undertake or commission a systematic review of all patients receiving repeat prescriptions of multiple analgesics and formulate individual plans for each such patient; ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Maintain a safety-netting system recording review dates and run monthly searches to identify new patients requiring inclusion.

Verbatim wording from the response
“8. Safety netting has been put in place to ensure the various risk groups will always be reviewed going forward - collating each patient’s last review date and their next review date. Searches will be run every month to identify any new patients who will need adding to this group.”

Source location
Response from Donneybrook Medical Centre
Page 2 · response
Published 20 September 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Use medicines-optimisation support to identify, categorise and prioritise patients receiving repeat prescriptions for multiple analgesics.

Verbatim wording from the response
“1. We have utilised the help from the Medicines Optimisation Team at the GMICB (previously CCG) to assist, categorise and prioritise patients receiving repeat prescriptions of multiple analgesics.”

Source location
Response from Donneybrook Medical Centre
Page 1 · response
Published 20 September 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Employ locum agency staff while pharmacist recruitment is ongoing.

Verbatim wording from the response
“9. The practice will recruit a pharmacist who will support this work and while the recruitment is ongoing locum agency staff will be employed.”

Source location
Response from Donneybrook Medical Centre
Page 2 · response
Published 20 September 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Limit prescription durations according to risk category and automatically arrange GP review when prescriptions become due.

Verbatim wording from the response
“7. A plan has been put into place to introduce a limitation on how many months prescriptions can be given before a patient’s next review; this is 3 months in the red priority, 6 months in the amber priority and 12 months in the green. Once a review is due the prescription clerk will highlight this then an appointment will be automatically made with the GP for further review.”

Source location
Response from Donneybrook Medical Centre
Page 2 · response
Published 20 September 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Recruit a pharmacist to support the medicines-management work.

Verbatim wording from the response
“9. The practice will recruit a pharmacist who will support this work and while the recruitment is ongoing locum agency staff will be employed.”

Source location
Response from Donneybrook Medical Centre
Page 2 · response
Published 20 September 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review patients on the red, amber and green priority lists, including checking previous reviews and recording required follow-up dates.

Verbatim wording from the response
“4. In addition, all patients identified in the search who have already had a review within the last 12 months will be checked, quality of the review and any instructions or call backs noted. If necessary they will be added into the Red/Amber/Green urgency categories for a”

Source location
Response from Donneybrook Medical Centre
Page 1 · response
Published 20 September 2022
Open published response

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 raised4

Inadequate specialist input for patients prescribed multiple analgesics on repeat prescription

Failure of GP practices with significant numbers of patients with complex analgesia regimes to engage practice pharmacists

Lack of systematic review of patients receiving repeat prescriptions of multiple analgesics

Failure to formulate individual plans for patients receiving repeat prescriptions of multiple analgesics

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.6

Actions described in response 6