Recipient

High Street Surgery

First report 27 Jun 2022•Latest report 27 Jun 2022

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: 1
Published responses: 100%
Concerns addressed: 4
Stated actions: 6

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.

100%published responses found

6stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from High Street Surgery linked to the concerns in each report. Select any concern, action or position to view the source wording.

27 Jun2022
East London
Concerns raised4
1. Failure to monitor the frequency of PRN medication administration
2. Lack of meaningful review of insomnia medication prescriptions
3. Failure to share dependence information with the mental health trust
1. Failure to limit prolonged prescribing of insomnia medication
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Hold practice staff meetings to explain the Z-Drug protocol and require repeat-prescription requests to be referred for medication review.
  Stated completed
2. Action
  Implement a local Z-Drug protocol requiring structured medication reviews at defined intervals and after relevant mental-health review.
  Stated completed
3. Action
  Audit and clinically review all patients prescribed Zopiclone over the previous two years, including structured reviews and a second-cycle review of repeat prescriptions.
  Stated completed
1. Action
  Commence more proactive referral of patients appearing dependent on Z-Drug hypnotics to specialist mental-health services for review and advice.
  Stated in progress
Respondent positions 2
1. Position
  Review of hypnotic prescriptions is assigned to the primary prescriber, with Trust clinicians reviewing prescriptions within their treatment scope.
  Redirects responsibility
1. Position
  The Trust, through its pharmacy services, is responsible for the wider Z-drug prescribing audit and safe-prescribing training package.
  Redirects responsibility
AI-generated summary

Michael John Vince · 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

Michael John Vince, a patient of the community mental health team receiving treatment for schizo-affective disorder, was found deceased at home on 19 June 2021 after apparently taking an overdose. The concerns included prolonged prescribing of medication for insomnia, lack of meaningful prescription review, failure to share evidence of dependence, and failure to monitor the frequency of PRN administration.

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 High Street Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to monitor the frequency of PRN medication administration
Wider context from the report
“4. The frequency with which Mr Vince was administering his PRN ████████ was never monitored. ”
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 High Street Surgery; that does not assign responsibility.
PFD Monitor interpretation
Lack of meaningful review of insomnia medication prescriptions
Wider context from the report
“2. No evidence exists to support that Mr Vince’s GP or community mental health team meaningfully reviewed his prescription ████████. ”
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 High Street Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to share dependence information with the mental health trust
Wider context from the report
“3. Evidence of Mr Vince’s dependence upon ████████ was not shared by his GP with the mental health trust. ”
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 High Street Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to limit prolonged prescribing of insomnia medication
Wider context from the report
“1. The NICE guidelines for ████████ indicate that it is a suitable medication for the short term treatment of insomnia, it advises against prolonged use due to risk of tolerance and withdrawal symptoms. Mr Vince is said to have been prescribed ████████ for 20 years. ”
Open source report
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
Hold practice staff meetings to explain the Z-Drug protocol and require repeat-prescription requests to be referred for medication review.

Verbatim wording from the response
“C. Discussion and Education of Practice Staff”

Source location
Response from High St Surgery
Page 2 · response
Published 23 September 2022
Open published response
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 a local Z-Drug protocol requiring structured medication reviews at defined intervals and after relevant mental-health review.

Verbatim wording from the response
“B. Implementation of Z-Drug Protocol”

Source location
Response from High St Surgery
Page 2 · response
Published 23 September 2022
Open published response
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 and clinically review all patients prescribed Zopiclone over the previous two years, including structured reviews and a second-cycle review of repeat prescriptions.

Verbatim wording from the response
“A. Clinical Audit of all patients prescribed Zopiclone over the past 2 years:”

Source location
Response from High St Surgery
Page 2 · response
Published 23 September 2022
Open published response
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
Commence more proactive referral of patients appearing dependent on Z-Drug hypnotics to specialist mental-health services for review and advice.

Verbatim wording from the response
“For my part, I have commenced more proactive referral of patients who appear dependent upon Z-Drug hypnotics for review and advice by specialist NELFT Mental Health services. This has been assisted by the response of the NELFT to the Coronal recommendations and the discussion and collaboration that has resulted. My practice’s Z-Drug Protocol includes a requirement for structured medication review for patients on long term Z-Drugs with mental health issues, and a requirement to notify the Mental Health Team for those patients who request additional Z drugs.”

Source location
Response from High St Surgery
Page 3 · response
Published 23 September 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review of hypnotic prescriptions is assigned to the primary prescriber, with Trust clinicians reviewing prescriptions within their treatment scope.

Verbatim wording from the response
“At that meeting the importance of proper communication between local GP’s, the NELFT Mental Health Team and other clinical services was discussed. It was agreed that review of hypnotics was the responsibility of the primary prescriber, but also the prescriptions should be reviewed by the Trust clinicians when in the scope of treatment provided by that clinician.”

Source location
Response from High St Surgery
Page 3 · response
Published 23 September 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Trust, through its pharmacy services, is responsible for the wider Z-drug prescribing audit and safe-prescribing training package.

Verbatim wording from the response
“The Trust committed to undertaking a wider audit of Z-Drug prescribing within the NELFT localities which will be led by the Trust pharmacy services. They will also be developing a safe-prescribing training package and will include education of local GP’s in their roll-out of this package.”

Source location
Response from High St Surgery
Page 3 · response
Published 23 September 2022
Open published response

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 raised4

Failure to monitor the frequency of PRN medication administration

Lack of meaningful review of insomnia medication prescriptions

Failure to share dependence information with the mental health trust

Failure to limit prolonged prescribing of insomnia medication

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.4

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 4

Respondent positions 2