Recipient

Eltham Medical Practice

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First report 14 Mar 2014•Latest report 14 Mar 2014

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

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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

  1. Addressed to Eltham Park Surgery, now represented here by Eltham Medical Practice.

    Inner South London

    AI-generated summary

    Teresa Lonergan · 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

    Teresa Lonergan, aged 73, was found dead at home on 4 September 2012 after taking an overdose of morphine that she had hoarded. The concerns included large quantities of prescribed morphine being available, repeat prescriptions and no reported monitoring of her consumption of controlled drugs.

    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 Eltham Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to monitor consumption of prescribed controlled drugs

    Wider context from the report

    “(1) At the scene the following bottles of morphine were found: 1 100 ml bottle 10mg/5mls 10% remaining, dated 21/02/12 1 100 ml bottle 10mg/5ml 30% remaining, dated 09/03/12 1 100 ml bottle 10mg/5ml 33% remaining, dated 08/05/12 1 100 ml bottle 10mg/5ml 75% remaining ? date 1 100 ml bottle 10mg/5ml, full, dated 13/07/12 and 3 loose strips of 10mg Zomorph with 23 of 28 remaining It was calculated that if the liquid morphine alone was considered there was 340mg available. The pathologist advised that 100 to 200mg would probably be sufficient to cause a fatality. (2) She was a retired matron. She was visited twice daily by her care worker, who opened her bottles for her as she was not able to do so herself. She did not report any medical instructions from doctors about administration or monitoring. Her GP issued repeat prescriptions of: 10mg Zomorph MR3 capsules 1 dse (issue up to 120), last issued 03/05/12 Morphine sulphate 10mg/5ml qds prn (issue up to 200mls)last issued 11/07/12. This was in addition to regular benzodiazepines and other non controlled analgesia. It was reported that she was visited several times a year by the surgery and kept in contact on the phone. There was no report of any monitoring of her consumption of controlled drugs, but the evidence from the general practice was read. She appeared to continue to draw prescriptions but not consume them as prescribed, thus building up a hoard, and providing the means for a deliberate overdose to be taken. ”
    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 Eltham Medical Practice; that does not assign responsibility.

    PFD Monitor interpretation

    Availability of potentially fatal quantities of morphine for overdose

    Wider context from the report

    “(1) At the scene the following bottles of morphine were found: 1 100 ml bottle 10mg/5mls 10% remaining, dated 21/02/12 1 100 ml bottle 10mg/5ml 30% remaining, dated 09/03/12 1 100 ml bottle 10mg/5ml 33% remaining, dated 08/05/12 1 100 ml bottle 10mg/5ml 75% remaining ? date 1 100 ml bottle 10mg/5ml, full, dated 13/07/12 and 3 loose strips of 10mg Zomorph with 23 of 28 remaining It was calculated that if the liquid morphine alone was considered there was 340mg available. The pathologist advised that 100 to 200mg would probably be sufficient to cause a fatality. (2) She was a retired matron. She was visited twice daily by her care worker, who opened her bottles for her as she was not able to do so herself. She did not report any medical instructions from doctors about administration or monitoring. Her GP issued repeat prescriptions of: 10mg Zomorph MR3 capsules 1 dse (issue up to 120), last issued 03/05/12 Morphine sulphate 10mg/5ml qds prn (issue up to 200mls)last issued 11/07/12. This was in addition to regular benzodiazepines and other non controlled analgesia. It was reported that she was visited several times a year by the surgery and kept in contact on the phone. There was no report of any monitoring of her consumption of controlled drugs, but the evidence from the general practice was read. She appeared to continue to draw prescriptions but not consume them as prescribed, thus building up a hoard, and providing the means for a deliberate overdose to be taken. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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