Fitzalan Medical Group

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First report 24 Oct 2017•Latest report 24 Oct 2017

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
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. West Sussex

    AI-generated summary

    David Edward Jackson · 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

    David Edward Jackson, a 76-year-old man, fell at home and remained on the floor for about two weeks before he died on 17 July 2017. His death was recorded as accidental, with severe pressure sores associated with sepsis, toxaemia and rhabdomyolysis following prolonged immobility. Concerns included long-term repeat prescribing of Co-dydramol and Soneryl without regular face-to-face medical review, and unclear arrangements for prescription collection or delivery.

    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 Fitzalan Medical Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct timely and sufficiently informed medication reviews for long-term repeat prescriptions

    Wider context from the report

    “Over the next 10 years, the records note a medication review was conducted by ████████ on 21 Oct 2008 and 2 March 2010 but on the records alone. There is one entry on the patient record for ████████ on 23 November 2015 noting only ‘medication review done’. When giving evidence, ████████ indicated that when ████████ retired in 2015 she took over Mr Jackson as a patient but she had never actually seen him. Her recollection was that she had conducted annual medication reviews by considering the patient's past history but only one is noted on the record printout. GMC good practice guidance was discussed with ████████ as follows: • Good medical practice (2013) – para 16: In providing clinical care you must prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient's health, and are satisfied that the drugs or treatment serve the patient's needs; and, • Prescribing and Managing Medicines (2013) – paragraphs 51; 54; 55; 56; 59 o 51: Whether you prescribe with repeats or on a oneoff basis, you must make sure that suitable arrangements are in place for monitoring, follow-up and review, taking account of the patients' needs and any risks arising from the medicines. o 54: Pharmacists can help improve safety, efficacy and adherence in medicines use, for example by advising patients about their medicines and carrying out medicines reviews. This does not relieve you of your duty to ensure that your prescribing and medicines management is appropriate… o 55: You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate. You should consider the benefits of prescribing with repeats to reduce the need for repeat prescribing. o 56: As with any prescription, you should agree with the patient what medicines are appropriate and how their condition will be managed, including a date for review. You should make clear why regular reviews are important and explain to the patient what they should do if they: a) suffer side effects or adverse reactions, or b) stop taking the medicines before the agreed review date (or a set number of repeats have been issued), You must make clear records of these discussions and your reasons for repeat prescribing. o 59: When you issue repeat prescriptions or prescribe with repeats, you should make sure that procedures are in place to monitor whether the medicine is still safe and necessary for the patient. You should keep a record of dispensers who hold original repeat dispensing prescriptions so that you can contact them if necessary. 1. When asked about current practice in relation to issuing prescriptions for drugs such as Soneryl or Co-dydramol ████████ acknowledged national guidance had tightened up particularly in respect of issuing prescriptions to patients for opiate based drugs. She accepted that medical thinking had moved on considerably. She was candid and accepted that in respect of Mr Jackson he had not been seen for 10 years and must have fallen through the cracks in terms of medication reviews including a period when the surgery had a shortage of doctors. This suggests a need to review: a. how and when medication reviews are carried out in the Fitzalan Medical Group; b. a potential training need for group doctors in GMC good practice; or, c. the development of a local CCG/Group policy. ”
    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 Fitzalan Medical Group; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate recording of medication reviews and reasons for repeat prescribing

    Wider context from the report

    “Over the next 10 years, the records note a medication review was conducted by ████████ on 21 Oct 2008 and 2 March 2010 but on the records alone. There is one entry on the patient record for ████████ on 23 November 2015 noting only ‘medication review done’. When giving evidence, ████████ indicated that when ████████ retired in 2015 she took over Mr Jackson as a patient but she had never actually seen him. Her recollection was that she had conducted annual medication reviews by considering the patient's past history but only one is noted on the record printout. GMC good practice guidance was discussed with ████████ as follows: • Good medical practice (2013) – para 16: In providing clinical care you must prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient's health, and are satisfied that the drugs or treatment serve the patient's needs; and, • Prescribing and Managing Medicines (2013) – paragraphs 51; 54; 55; 56; 59 o 51: Whether you prescribe with repeats or on a oneoff basis, you must make sure that suitable arrangements are in place for monitoring, follow-up and review, taking account of the patients' needs and any risks arising from the medicines. o 54: Pharmacists can help improve safety, efficacy and adherence in medicines use, for example by advising patients about their medicines and carrying out medicines reviews. This does not relieve you of your duty to ensure that your prescribing and medicines management is appropriate… o 55: You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate. You should consider the benefits of prescribing with repeats to reduce the need for repeat prescribing. o 56: As with any prescription, you should agree with the patient what medicines are appropriate and how their condition will be managed, including a date for review. You should make clear why regular reviews are important and explain to the patient what they should do if they: a) suffer side effects or adverse reactions, or b) stop taking the medicines before the agreed review date (or a set number of repeats have been issued), You must make clear records of these discussions and your reasons for repeat prescribing. o 59: When you issue repeat prescriptions or prescribe with repeats, you should make sure that procedures are in place to monitor whether the medicine is still safe and necessary for the patient. You should keep a record of dispensers who hold original repeat dispensing prescriptions so that you can contact them if necessary. 1. When asked about current practice in relation to issuing prescriptions for drugs such as Soneryl or Co-dydramol ████████ acknowledged national guidance had tightened up particularly in respect of issuing prescriptions to patients for opiate based drugs. She accepted that medical thinking had moved on considerably. She was candid and accepted that in respect of Mr Jackson he had not been seen for 10 years and must have fallen through the cracks in terms of medication reviews including a period when the surgery had a shortage of doctors. This suggests a need to review: a. how and when medication reviews are carried out in the Fitzalan Medical Group; b. a potential training need for group doctors in GMC good practice; or, c. the development of a local CCG/Group policy. ”
    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 Fitzalan Medical Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to establish and record arrangements for repeat prescription collection, delivery and pharmacy coordination

    Wider context from the report

    “2. ████████ was also asked how were repeat prescriptions requested, collected or delivered. She was unable to help me in Mr Jackson's case but referred to a potential patient advocate, I believe meaning the person who nominated to collect his prescription. In this case for some time that was ████████ but given her increasing immobility this may have been a neighbour. ████████ also referred to working with local pharmacists but the details are unclear. This again suggests a need to review: a. the period of time that Mr Jackson remained on repeat prescriptions without being seen; b. the unknown arrangements for collection or delivery; and, c. possibly the arrangements with local pharmacies. ”
    Open source report
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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