Recipient

Family of Julia Macpherson

First report 1 Apr 2018•Latest report 1 Apr 2018

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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 Family of Julia Macpherson linked to the concerns in each report. Select any concern, action or position to view the source wording.

1 Apr2018
South London
Concerns raised6
1. Failure to follow NICE guidelines for prescribing off-licence medicines
2. Failure to provide timely clinical review following reported deterioration
3. Failure of hospital staff to regularly read clinical and nursing entries in patient medical records
1. Failure to formally review mental capacity to consent to treatment
2. Absence of a statutory process for recording informal patients' consent to medication
3. Incomplete or missing records of consent discussions for off-licence mental health medication
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Julia Jane MacPherson · 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

Julia Jane MacPherson, an informal patient of Oxleas NHS Foundation Trust, suffered swallowing difficulties and collapsed in the community with food bolus and vomitus in her throat; resuscitation was unsuccessful. Concerns included failure to arrange or undertake a timely medical review, failure to assess her mental capacity after concerns about confusion, incomplete clinical records, and prescribing and consent processes for off-licence medication. The inquest recorded the medical cause of death as upper airway obstruction associated with swallowing difficulties secondary to medication-related extrapyramidal symptoms.

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 Family of Julia Macpherson; that does not assign responsibility.
PFD Monitor interpretation
Failure to follow NICE guidelines for prescribing off-licence medicines
Wider context from the report
“(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal 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 Family of Julia Macpherson; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide timely clinical review following reported deterioration
Wider context from the report
“(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal 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 Family of Julia Macpherson; that does not assign responsibility.
PFD Monitor interpretation
Failure of hospital staff to regularly read clinical and nursing entries in patient medical records
Wider context from the report
“(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal 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 Family of Julia Macpherson; that does not assign responsibility.
PFD Monitor interpretation
Failure to formally review mental capacity to consent to treatment
Wider context from the report
“(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal 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 Family of Julia Macpherson; that does not assign responsibility.
PFD Monitor interpretation
Absence of a statutory process for recording informal patients' consent to medication
Wider context from the report
“(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal 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 Family of Julia Macpherson; that does not assign responsibility.
PFD Monitor interpretation
Incomplete or missing records of consent discussions for off-licence mental health medication
Wider context from the report
“(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients. ”
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 raised6

Failure to follow NICE guidelines for prescribing off-licence medicines

Failure to provide timely clinical review following reported deterioration

Failure of hospital staff to regularly read clinical and nursing entries in patient medical records

Failure to formally review mental capacity to consent to treatment

Absence of a statutory process for recording informal patients' consent to medication

Incomplete or missing records of consent discussions for off-licence mental health medication