Eltham Palace Surgery

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First report 27 Oct 2014•Latest report 27 Oct 2014

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

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
6

Described in responses

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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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