Concerns raised 4 Lack of alerts for new medications subject to repeat prescription View source Failure to notify relevant support services and contacts after patient self-discharge View source Failure to record externally requested new medications on repeat prescriptions View source Lack of a protocol for patients self-discharging from hospital without necessary medication View source See 1 more concern
Responses linked to these concerns
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AI-generated summary
Terence Ryan · 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
Terence Ryan died on 14 November 2016 after a road traffic collision caused a left leg fracture and he later self-discharged from hospital without anticoagulation medication. The report identified concerns about a consultant-prescribed anticoagulant not being added to his repeat prescriptions and the absence of a hospital protocol for patients, particularly vulnerable patients, who self-discharge without necessary medication.
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 Grasmere Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of alerts for new medications subject to repeat prescription
Wider context from the report “i. On the 15th July 2016 a Consultant prescribed Edoxaban 60mg per day for long term anticoagulation treatment to be collected by the deceased on a weekly basis by repeat prescription issued by the General Practitioner and the Consultant sent a letter to the General Practitioner to confirm that plan of treatment. The repeat prescription for Edoxaban was not put on the deceased’s repeat prescriptions by the General Practitioner and the deceased did not receive Edoxaban for administration after the 22nd July 2016 and he would not have had a supply of Edoxaban following his self-discharge from the Hospital on the 10th November 2016.
The General Practitioner gave evidence that the Surgery had undertaken a “Significant Event Analysis” as to how the Edoxaban prescription had been missed and the investigation resulted in the following recommendations within the Surgery to prevent a recurrence:-
a. GP to review “active problems” on the computer system when any patient comes in, in order to ensure patient is on the appropriate treatment.
b. In respect of discharge letters directing new medication – the letter will be sent on a task to a prescription clerk, who will add the new medication and issue a month’s supply. If necessary (depending on the type of medication involved) the task will include sending a request to the patient to see the GP for review in a month’s time.
However, the General Practitioner confirmed that the above recommendations had not been included in any formal documented protocol and I was not satisfied that there was to be a note on a patient’s record to alert a Doctor to a new medication subject to repeat prescription , bearing in mind that the deceased had seen a General Practitioner on the 13th September 2016, the 30th September 2016 and the 14th October 2016 without the omission being checked .
” 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 Grasmere Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to notify relevant support services and contacts after patient self-discharge
Wider context from the report “ii. The evidence at the Inquest revealed that the Wrightington, Wigan and Leigh NHS Foundation Trust does not have a protocol with regard to patients who self-discharge from the Hospital, particularly where they may be receiving necessary medication in the form of anticoagulation treatment. At the Inquest the deceased was identified as an vulnerable patient and the absence of a protocol is even more important in relation to a vulnerable patient.
There is no protocol to contact the Police, General Practitioner, Family or Social Services to bring it to their attention that a patient has self-discharged so that they become aware and they can make contact with the patient following his discharge to ensure that he has appropriate support and necessary 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 Grasmere Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to record externally requested new medications on repeat prescriptions
Wider context from the report “i. On the 15th July 2016 a Consultant prescribed Edoxaban 60mg per day for long term anticoagulation treatment to be collected by the deceased on a weekly basis by repeat prescription issued by the General Practitioner and the Consultant sent a letter to the General Practitioner to confirm that plan of treatment. The repeat prescription for Edoxaban was not put on the deceased’s repeat prescriptions by the General Practitioner and the deceased did not receive Edoxaban for administration after the 22nd July 2016 and he would not have had a supply of Edoxaban following his self-discharge from the Hospital on the 10th November 2016.
The General Practitioner gave evidence that the Surgery had undertaken a “Significant Event Analysis” as to how the Edoxaban prescription had been missed and the investigation resulted in the following recommendations within the Surgery to prevent a recurrence:-
a. GP to review “active problems” on the computer system when any patient comes in, in order to ensure patient is on the appropriate treatment.
b. In respect of discharge letters directing new medication – the letter will be sent on a task to a prescription clerk, who will add the new medication and issue a month’s supply. If necessary (depending on the type of medication involved) the task will include sending a request to the patient to see the GP for review in a month’s time.
However, the General Practitioner confirmed that the above recommendations had not been included in any formal documented protocol and I was not satisfied that there was to be a note on a patient’s record to alert a Doctor to a new medication subject to repeat prescription, bearing in mind that the deceased had seen a General Practitioner on the 13th September 2016, the 30th September 2016 and the 14th October 2016 without the omission being checked.
” 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 Grasmere Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for patients self-discharging from hospital without necessary medication
Wider context from the report “ii. The evidence at the Inquest revealed that the Wrightington, Wigan and Leigh NHS Foundation Trust does not have a protocol with regard to patients who self-discharge from the Hospital , particularly where they may be receiving necessary medication in the form of anticoagulation treatment . At the Inquest the deceased was identified as an vulnerable patient and the absence of a protocol is even more important in relation to a vulnerable patient.
There is no protocol to contact the Police, General Practitioner, Family or Social Services to bring it to their attention that a patient has self-discharged so that they become aware and they can make contact with the patient following his discharge to ensure that he has appropriate support and necessary medication.
” 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 Study and discuss the repeat prescribing and scanning protocols at a practice meeting.
Verbatim wording from the response “I enclose copies of our Repeat Prescribing Protocol; this includes the ‘Protection on Prescribing’ including hospital letters.” Source location 2017-0225-Response-by-Grasmere-Surgery
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 Arrange a follow-up meeting in three months to review how the prescribing protocol is working within the practice.
Verbatim wording from the response “A further meeting will be arranged in three month's time to review how the Prescribing Protocol has been working within the Practice.” Source location 2017-0225-Response-by-Grasmere-Surgery
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 Meet with all receptionists and nurses to address the protocols.
Verbatim wording from the response “I enclose copies of our Repeat Prescribing Protocol; this includes the ‘Protection on Prescribing’ including hospital letters.” Source location 2017-0225-Response-by-Grasmere-Surgery
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations