Recipient

Eltham Palace Surgery

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First report 27 Oct 2014•Latest report 27 Oct 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
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
6

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.

100%published responses found
6stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Eltham Palace Surgery linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner South London

    AI-generated summary

    Philip Allen · 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

    Philip Allen, who had vascular dementia, was transferred from The Oaks Care Centre to QEH in September 2012 following a deterioration in his condition and died there. The concern was that Quetiapine continued to be prescribed as a repeat prescription after specialist advice to discontinue it, because the surgery’s system did not prevent this; the inquest evidence was that the further prescriptions did not contribute to his death.

    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 Palace Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to follow specialist prescribing advice

    Wider context from the report

    “████████ as Mr Allen’s GP, sought specialist advice from ████████. Not only was this advice not followed but the Quetiapine, which ████████ had stopped, continued to be prescribed as a repeat prescription on several occasions. The evidence at the inquest was that the further prescriptions of Quetiapine did not contribute to the death. However, I am concerned that the system at Eltham Palace Surgery did not prevent the repeat prescription. ████████ was unable to say if changes have been made since this incident. ”
    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 Palace Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the repeat-prescribing system to prevent prescriptions of discontinued medication

    Wider context from the report

    “████████ as Mr Allen’s GP, sought specialist advice from ████████. Not only was this advice not followed but the Quetiapine, which ████████ had stopped, continued to be prescribed as a repeat prescription on several occasions. The evidence at the inquest was that the further prescriptions of Quetiapine did not contribute to the death. However, I am concerned that the system at Eltham Palace Surgery did not prevent the repeat prescription. ████████ was unable to say if changes have been made since this incident. ”
    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

    Carry out twice-yearly medication reviews using the practice computer records and electronic prescribing system.

    Verbatim wording from the response

    “As a practice we have made several changes to our policy in dealing with the care of clients at the Oaks Nursing Home:-”

    Source location

    2014-0466-Response-by-Eltham-Palace-Surgery
    Page 2 · response
    Published 27 October 2014

    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

    Carry out quarterly medication reviews through the CCG Prescribing Advisor.

    Verbatim wording from the response

    “As a practice we have made several changes to our policy in dealing with the care of clients at the Oaks Nursing Home:-”

    Source location

    2014-0466-Response-by-Eltham-Palace-Surgery
    Page 2 · response
    Published 27 October 2014

    Open published response
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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

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

How actions were described at the time

This respondent
83%17%
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