Greater Manchester Medicines Management Group

Private and voluntary organisations · Health professional committee

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First report 22 Apr 2020•Latest report 20 Feb 2026

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
2

Naming this recipient

Published responses
50%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
7

Described in responses

Concerns and recipient responses

Statements from Greater Manchester Medicines Management Group linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Cheshire

    AI-generated summary

    Alan CRABTREE · 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

    Alan Crabtree was prescribed methotrexate on 3 February 2025, developed rapid-onset pancytopenia, was admitted to hospital on 18 February, and died of pneumonia on 1 March 2025. The report identified concerns that the methotrexate dosing guidance was outdated and that its advice about which healthcare professional patients should contact for signs of toxicity was ambiguous, potentially delaying appropriate treatment.

    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 Greater Manchester Medicines Management Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the methotrexate guideline to provide a current therapeutic initial dose

    Wider context from the report

    “1. The dose regime referred to in the “Shared Care Guideline for Oral Methotrexate in Rheumatological Conditions in Adults” does not reflect current practice and the initial dose recommended is a sub-therapeutic dose. ”
    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 Greater Manchester Medicines Management Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the methotrexate guideline to define current responsibilities and direct patients to the appropriate healthcare professional

    Wider context from the report

    “2. The “Shared Care Guideline for Oral Methotrexate in Rheumatological Conditions in Adults” was produced in September 2017. Since then, the “Pharmacy First” scheme has come into effect. The guidance therefore does not reflect the changes in the relevant responsibilities between secondary care, GPs and community pharmacists leading to ambiguity as to what type of healthcare professional a patient should consult and potentially fatal delay in ceasing methotrexate or commencing treatment for toxicity for the same. ”
    Open source report

  2. Manchester South

    AI-generated summary

    SAM ROBSON PRINGLE · 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

    Sam Pringle had a long history of mental health problems and died by suicide by hanging on 3 November 2018. The report raised concern that inconsistent prescribing practices and the shared care protocol could delay or prevent access to Lithium for mentally ill patients, with potentially fatal results.

    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 Greater Manchester Medicines Management Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of psychiatrists to comply with the shared care protocol when requesting GP initiation of Lithium prescriptions

    Wider context from the report

    “(1) The inquest heard evidence that some psychiatrists are asking GPs to instigate prescriptions of Lithium, knowing that the shared care protocol (should) prevent GPs from doing so; as a result the provision of Lithium to mentally ill patients is either not happening or is being delayed, with potentially fatal results. ”
    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