Heaton Moor Medical Group

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First report 14 Mar 2018•Latest report 19 Sep 2019

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
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Manchester South

    AI-generated summary

    Kathryn Mary Barrow · 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

    Kathryn Mary Barrow was found dead at her home on 7 March 2019, aged 59, after a long history of mental illness and treatment for bipolar affective disorder. A post-mortem did not establish a medical cause of death, and the inquest recorded an Open conclusion. Concerns related to the prescribing of Diazepam, including inadequate documentation or checks, whether access to the medicine illicitly had been considered, and the practice’s lack of a recent review of its prescribing approach.

    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 Heaton Moor Medical Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to verify mental health service advice before prescribing Diazepam

    Wider context from the report

    “1. Having claimed this has been advised by her Consultant Psychiatrist, Mrs Barrow has obtained short course prescriptions for Diazepam from the surgery apparently without further documentation being received from mental health services to confirm this, or without further checks being made by the GP; ”
    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 Heaton Moor Medical Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to review the approach to prescribing Diazepam

    Wider context from the report

    “3. The court heard evidence that the practice has not recently undertaken any review of its approach to prescribing Diazepam. ”
    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 Heaton Moor Medical Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to assess illicit access to Diazepam

    Wider context from the report

    “2. From the evidence heard at court, doctors at the practice prescribing Diazepam to Mrs Barrow do not appear to have sought to ascertain whether or not she may have access to this medicine illicitly; ”
    Open source report

  2. Manchester South

    AI-generated summary

    Peter STOJILJKOVIC · 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

    Peter Stojiljkovic was discharged from hospital on 9 June 2017 after being prescribed melatonin and was later found suspended by a ligature at his home on 22 July 2017. The concerns included poor communication between the hospital, GP and Peter about community prescribing, differing prescribing policies, the complexity of prescribing guidance, and the possibility that he would need to obtain melatonin from unlicensed sources. There was also no evidence of communication with the GP before discharge to support a smooth transition into the community.

    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 Heaton Moor Medical Group; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of consistent and clear prescribing guidance across local and national lists

    Wider context from the report

    “2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists. It was unclear why Stockport CCG took a different approach to other CCGs 3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty. ”
    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 Heaton Moor Medical Group; that does not assign responsibility.

    PFD Monitor interpretation

    Risk of patients obtaining melatonin from unlicensed internet sources

    Wider context from the report

    “4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it. This created a risk that he would have to access the drug from unlicensed sources. ”
    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 Heaton Moor Medical Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate with community GPs before discharge about ongoing melatonin prescribing

    Wider context from the report

    “1. The deceased had been prescribed melatonin whilst an in-patient. The inquest heard that post his discharge communication between the hospital; GP and Mr Stojiljkovic was such that he was unaware that his GP was prepared to prescribe melatonin in the community; 2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists. It was unclear why Stockport CCG took a different approach to other CCGs 3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty. 4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it. This created a risk that he would have to access the drug from unlicensed sources. 5. It was known whilst he was an in-patient that difficulties with prescribing melatonin in the community would arise. There was no evidence of any attempt to communicate with the GP prior to discharge to ensure a smooth discharge into the community. ”
    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