25 Jul 2022 Natalie Mortimer · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 3 Failure to update the medical record with hospital discharge information about a previous overdose attempt View source Failure to maintain coded overdose alerts in patient records View source Reliance on default prescription quantities without adequate quantity validation 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. 6
Action
Introduce a correspondence triage policy and flow chart to route relevant information to appropriate staff.
View source
Action
Add colchicine safety alerts to patient records, recommending quantity limitation and risk assessment for patients with relevant mental-health histories.
View source
Action
Implement patient-record alerts that display relevant safety concerns at login until acknowledged.
View source
Action
Encourage clinicians to use Arden depression-review templates incorporating self-harm questions and automatic risk alerts.
View source
Action
Employ a full-time read-coder to ensure correspondence is read-coded and necessary patient alerts are added.
View source
Action
Audit Docman for coding, document routing, follow-up completion and escalation of concerns, with audits every three months.
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AI-generated summary
Natalie Mortimer · 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
Natalie Mortimer died on 21 April 2022 at St Thomas' Hospital after an overdose of colchicine tablets prescribed for gout. She developed multiorgan failure. Concerns included that information about a previous overdose was not added to her GP record and that 100 tablets were prescribed because this was the system default, without an alert identifying the previous overdose.
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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 Green Porch Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to update the medical record with hospital discharge information about a previous overdose attempt
Wider context from the report “(1) The GP Practice received a discharge note from the hospital for a previous overdose attempt in April 2021. The patient’s medical record was not updated to reflect this information.
” 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 Green Porch Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain coded overdose alerts in patient records
Wider context from the report “(2) On the 25th November 2021 the patient attended the GP Practice and the GP on duty reviewed her most recent consultation which took place on the 22nd November 2021 and her records and prescribed the patient with ████████ to be taken 2-4 times a day until symptoms resolve for her gout. The GP detailed in evidence that she issued 100 tablets as this was the default quantity that came up on EMIS. The prescribing doctor stated that there were no alerts coding of a previous overdose in the patients records which may have been a contraindication for issuing a prescription of 100 tablets and therefore relied on the default quantity generated by the system.
” 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 Green Porch Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Reliance on default prescription quantities without adequate quantity validation
Wider context from the report “(2) On the 25th November 2021 the patient attended the GP Practice and the GP on duty reviewed her most recent consultation which took place on the 22nd November 2021 and her records and prescribed the patient with ████████ to be taken 2-4 times a day until symptoms resolve for her gout. The GP detailed in evidence that she issued 100 tablets as this was the default quantity that came up on EMIS . The prescribing doctor stated that there were no alerts coding of a previous overdose in the patients records which may have been a contraindication for issuing a prescription of 100 tablets and therefore relied on the default quantity generated by the system .
” 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 Introduce a correspondence triage policy and flow chart to route relevant information to appropriate staff.
Verbatim wording from the response “2. We have introduced a correspondence triage policy/flow chart – please find” Source location Response from Green Porch 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 Add colchicine safety alerts to patient records, recommending quantity limitation and risk assessment for patients with relevant mental-health histories.
Verbatim wording from the response “6. We have put alerts on patient records for anyone requesting colchicine (see example enclosed) regarding the toxicity to ensure that this is explained to the patient at their next review. The alert recommends limiting the colchicine to 12 tablets and if there is a history of Mental health, depression, Suicide attempt or self-harm, to carry out a risk assessment before issuing.” Source location Response from Green Porch 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 Implement patient-record alerts that display relevant safety concerns at login until acknowledged.
Verbatim wording from the response “3. We now have a system in place to ensure that relevant important alerts are put on the system for individual patients. This will initiate as soon as somebody logs into the records and an alert message will inform the clinician/administration/reception team what the concerns are. This will be on the screen until it is confirmed as acknowledged. Alerts will be in place for overdose attempt/Safeguarding issues/suicidal ideation/domestic violence etc.” Source location Response from Green Porch 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 Encourage clinicians to use Arden depression-review templates incorporating self-harm questions and automatic risk alerts.
Verbatim wording from the response “4. We have encouraged all clinicians to use the Arden templates for reviewing depression. Asking the patient about self-harm is incorporated as part of the template. This will also help to ensure patients safety as it automatically flags up as a red-code. i.e., history of self-harm/suicidal ideation/Overdose attempt etc.” Source location Response from Green Porch 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 Employ a full-time read-coder to ensure correspondence is read-coded and necessary patient alerts are added.
Verbatim wording from the response “We have reviewed this case in depth and have put the following steps in place to ensure that this does not happen in the future.” Source location Response from Green Porch 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 Audit Docman for coding, document routing, follow-up completion and escalation of concerns, with audits every three months.
Verbatim wording from the response “7. We are currently in the process of auditing Docman to ensure quality compliance i.e., read-code is appropriate, that the relevant team has seen the document, any follow ups completed, any concerns raised with the relevant department etc. Audits will be carried out every 3 months, starting 1st of December 2022.” Source location Response from Green Porch 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