Fremington Medical Centre

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First report 4 Aug 2017•Latest report 4 Aug 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
Published responses: 100%
Concerns addressed: 2
Stated actions: 8

Concerns and recipient responses

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

4 Aug2017
Exeter and Greater Devon
Concerns raised2
1. Failure to review patients receiving extended-term medication for suitability of continued long-term use
2. Failure to prescribe longer-acting rather than shorter-acting benzodiazepines for long-term use
Actions described in response 4
1. Action
  Audit patients prescribed Lorazepam and all practice patients receiving it on repeat prescription.
2. Action
  Send personal letters asking patients with repeat benzodiazepine prescriptions to arrange targeted medication reviews.
3. Action
  Remind prescribing staff to discuss short-term benzodiazepine use, conduct regular reviews, and avoid adding these medicines to repeat prescriptions.
1. Action
  Change future prescribing practice regarding switching short-acting benzodiazepines to longer-acting alternatives.
Respondent positions 1
1. Position
  Switching to a long-acting benzodiazepine was not considered warranted in this case because clinical indications outweighed the risks.
  Disputes the concern
AI-generated summary

Carly Marie GORDON · 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

Carly Marie GORDON was admitted to hospital after a failed attempt on her own life and was later found hanging at home on 27 May 2016 after being discharged to her mother's care. The inquest concluded that she took her own life while suffering from depressive disorder and benzodiazepine withdrawal; concerns related to the long-term prescribing and review of benzodiazepines.

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 Fremington Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to review patients receiving extended-term medication for suitability of continued long-term use
Wider context from the report
“(2) All patients who receive this drug for an extended period of time should be reviewed by their medical advisors to reassess their suitability for the long term use of this particular medication. ”
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 Fremington Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to prescribe longer-acting rather than shorter-acting benzodiazepines for long-term use
Wider context from the report
“(1) The long term use of shorter acting Benzodiazepine instead of longer acting Benzodiazepine in accordance with the British Association of Psychopharmacology Guidelines should be followed when patients are prescribed this drug to avoid dependence. ”
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
Audit patients prescribed Lorazepam and all practice patients receiving it on repeat prescription.

Verbatim wording from the response
“In regard to my own personal prescribing I have audited every patient I have prescribed Lorazepam to between 27/05/2016 and 13/09/2017.”

Source location
2017-0320-Response-by-Fremington-Medical-Centre
Page 3 · response
Published 3 December 2017
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
Send personal letters asking patients with repeat benzodiazepine prescriptions to arrange targeted medication reviews.

Verbatim wording from the response
“Reviewing medication is regular practice at our surgery. However we have now considered a structured systemic approach for patients on Benzodiazepines to those reviews following our own significant event discussion of this case and the regulation 28 report.”

Source location
2017-0320-Response-by-Fremington-Medical-Centre
Page 4 · response
Published 3 December 2017
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
Remind prescribing staff to discuss short-term benzodiazepine use, conduct regular reviews, and avoid adding these medicines to repeat prescriptions.

Verbatim wording from the response
“For those thought requiring acute prescriptions we have reminded prescribing staff of the requirement to discuss with patients about the short term use of Benzodiazepines and regular reviews of both symptoms and prescriptions; also, not to add these medications to repeat prescriptions. I hope my own personal audit evidences that.”

Source location
2017-0320-Response-by-Fremington-Medical-Centre
Page 4 · response
Published 3 December 2017
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
Change future prescribing practice regarding switching short-acting benzodiazepines to longer-acting alternatives.

Verbatim wording from the response
“• “Switching from a short half-life Benzodiazepine to a long half-life Benzodiazepine before gradual taper should be reserved for patients having problematic withdrawal symptoms”.”

Source location
2017-0320-Response-by-Fremington-Medical-Centre
Page 2 · response
Published 3 December 2017
Open published response
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
Switching to a long-acting benzodiazepine was not considered warranted in this case because clinical indications outweighed the risks.

Verbatim wording from the response
“• “Switching from a short half-life Benzodiazepine to a long half-life Benzodiazepine before gradual taper should be reserved for patients having problematic withdrawal symptoms”.”

Source location
2017-0320-Response-by-Fremington-Medical-Centre
Page 2 · response
Published 3 December 2017
Open published response

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 raised2

Failure to review patients receiving extended-term medication for suitability of continued long-term use

Failure to prescribe longer-acting rather than shorter-acting benzodiazepines for long-term use

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.4

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 4

Respondent positions 1