Recipient

Heaton Moor Medical Group

First report 14 Mar 2018•Latest report 19 Sep 2019

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

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.

19 Sep2019
Manchester South
Concerns raised3
1. Failure to verify mental health service advice before prescribing Diazepam
2. Failure to review the approach to prescribing Diazepam
3. Failure to assess illicit access to Diazepam
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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
14 Mar2018
Manchester South
Concerns raised3
1. Lack of consistent and clear prescribing guidance across local and national lists
2. Risk of patients obtaining melatonin from unlicensed internet sources
3. Failure to communicate with community GPs before discharge about ongoing melatonin prescribing
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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

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 raised3

Failure to verify mental health service advice before prescribing Diazepam

Failure to review the approach to prescribing Diazepam

Failure to assess illicit access to Diazepam

Concerns raised3

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

Risk of patients obtaining melatonin from unlicensed internet sources

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