30 Apr 2025 Louise Danielle ROSENDALE · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Limited review of long-term opiate prescribing View source Lack of long-term detailed planning and oversight of patients prescribed opiates View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Conduct follow-up audits of compliance with revised opioid prescribing protocols and safety measures, reviewing results and learning at practice meetings.
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Action
Complete an audit of high-risk opioid prescribing to identify improvement needs and support appropriate monitoring.
View source
Action
Revise opioid prescribing policy and introduce a prescribing protocol with escalation thresholds, rationale documentation and multidisciplinary oversight.
View source
Action
Complete a comprehensive review of opioid prescribing practices.
View source
Action
Require regular structured medication reviews for high-dose opioid prescriptions, with defined intervals and GP and pharmacist oversight.
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AI-generated summary
Louise Danielle ROSENDALE · 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
Louise Danielle Rosendale was prescribed long-term opiates for pain following previous surgery and was found unresponsive on 24 September 2024. She died from multiple drug toxicity and pneumonia; concerns included limited review of her long-term opiate prescribing and a lack of detailed planning or oversight for such patients within the practice.
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× 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 Flixton Road Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Limited review of long-term opiate prescribing
Wider context from the report “THE INQUEST HEARD EVIDENCE THAT Louise Rosendale had been prescribed opiates for many years despite the risks associated with long term opiate prescribing. The evidence before the inquest was that there had been very limited attempts to review the long term prescribing of opiates to her . The inquest was told that she had been identified as a patient on a long term opiate prescription in 2022. The next action had been a pharmacy review in July 2024.There was no evidence of long term detailed planning or oversight of these patients within the practice
” 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 Flixton Road Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of long-term detailed planning and oversight of patients prescribed opiates
Wider context from the report “THE INQUEST HEARD EVIDENCE THAT Louise Rosendale had been prescribed opiates for many years despite the risks associated with long term opiate prescribing. The evidence before the inquest was that there had been very limited attempts to review the long term prescribing of opiates to her. The inquest was told that she had been identified as a patient on a long term opiate prescription in 2022. The next action had been a pharmacy review in July 2024.There was no evidence of long term detailed planning or oversight of these patients within the practice
” Open source report
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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 Conduct follow-up audits of compliance with revised opioid prescribing protocols and safety measures, reviewing results and learning at practice meetings.
Verbatim wording from the response “To ensure the effectiveness of the actions taken and to support continuous improvement, we will implement follow-up audits to monitor compliance with revised protocols and safety measures related to opiate prescribing. The audit results and learning will be reviewed at our practice meeting, where we will strive to ensure all new processes are acknowledged and embedded by all the clinical team.” Source location Response from Flixton Road Medical Centre
Open published response
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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 Complete an audit of high-risk opioid prescribing to identify improvement needs and support appropriate monitoring.
Verbatim wording from the response “As part of the practice’s commitment to continuous learning and patient safety, a comprehensive review of opioid prescribing was undertaken. This included a revision of the opioid prescribing policy in line with current clinical guidelines, alongside the introduction of mandatory training for all prescribers to support safer opioid use. An audit of high-risk prescribing was completed to identify areas for improvement and ensure appropriate monitoring. Electronic safety alerts within the prescribing system were optimised to support clinical decision-making at the point of care. Structured medication reviews were reinforced as a routine part of ongoing care, particularly for patients on long-term high-dose opioids.” Source location Response from Flixton Road Medical Centre
Open published response
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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 Revise opioid prescribing policy and introduce a prescribing protocol with escalation thresholds, rationale documentation and multidisciplinary oversight.
Verbatim wording from the response “As part of the practice’s commitment to continuous learning and patient safety, a comprehensive review of opioid prescribing was undertaken. This included a revision of the opioid prescribing policy in line with current clinical guidelines, alongside the introduction of mandatory training for all prescribers to support safer opioid use. An audit of high-risk prescribing was completed to identify areas for improvement and ensure appropriate monitoring. Electronic safety alerts within the prescribing system were optimised to support clinical decision-making at the point of care. Structured medication reviews were reinforced as a routine part of ongoing care, particularly for patients on long-term high-dose opioids.” Source location Response from Flixton Road Medical Centre
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 Complete a comprehensive review of opioid prescribing practices.
Verbatim wording from the response “As part of the practice’s commitment to continuous learning and patient safety, a comprehensive review of opioid prescribing was undertaken. This included a revision of the opioid prescribing policy in line with current clinical guidelines, alongside the introduction of mandatory training for all prescribers to support safer opioid use. An audit of high-risk prescribing was completed to identify areas for improvement and ensure appropriate monitoring. Electronic safety alerts within the prescribing system were optimised to support clinical decision-making at the point of care. Structured medication reviews were reinforced as a routine part of ongoing care, particularly for patients on long-term high-dose opioids.” Source location Response from Flixton Road Medical Centre
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 Require regular structured medication reviews for high-dose opioid prescriptions, with defined intervals and GP and pharmacist oversight.
Verbatim wording from the response “As part of the practice’s commitment to continuous learning and patient safety, a comprehensive review of opioid prescribing was undertaken. This included a revision of the opioid prescribing policy in line with current clinical guidelines, alongside the introduction of mandatory training for all prescribers to support safer opioid use. An audit of high-risk prescribing was completed to identify areas for improvement and ensure appropriate monitoring. Electronic safety alerts within the prescribing system were optimised to support clinical decision-making at the point of care. Structured medication reviews were reinforced as a routine part of ongoing care, particularly for patients on long-term high-dose opioids.” Source location Response from Flixton Road Medical Centre
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Resource constraints limited the practice’s ability to undertake more proactive, structured opioid reviews.
Verbatim wording from the response “On reflection, several areas have been identified where care could have been improved. Earlier identification of risks associated with long-term high-dose opioid use may have prompted more timely interventions. Greater patient involvement in decision-making could have supported shared understanding and safer management plans. There was limited external input from specialist services in reviewing ongoing opioid prescribing, and an absence of a formal monitoring framework meant that risk mitigation strategies were not consistently applied. Resource constraints also impacted the ability to implement more proactive, structured reviews. Opportunities were missed for more proactive monitoring of opioid use, supported by a clear and structured communication protocol across the clinical team.” Source location Response from Flixton Road Medical Centre
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations