Hilltops Medical Centre

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First report 22 Feb 2023•Latest report 22 Feb 2023

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
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
9

Described in responses

Concerns and recipient responses

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

  1. Milton Keynes

    AI-generated summary

    Jacqueline Sharman CAMPBELL · 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

    Jacqueline Sharman CAMPBELL was found collapsed at home after living with chronic back pain for more than 20 years and taking multiple prescribed medicines. The inquest concluded that she likely inadvertently overdosed on tramadol, which in combination with other medicines had a synergistic effect causing respiratory depression and death. The principal concern was the safety risk of polypharmacy involving gabapentinoids and opioids, particularly their cumulative and synergistic effects on the central nervous system.

    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 Hilltops Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to actively identify patients taking high-risk medication combinations and rationalize or reduce their medications

    Wider context from the report

    “Her GP, ████████, gave clear and candid evidence. I accept the management of patients who describe intractable debilitating pain is challenging and difficult and that requests for other or increasing doses of medication can be difficult to resist. ████████ agreed that the prescribing of the various drugs identified had potential to be dangerous. He told me that after a certain point the benefits of increasing or adding doses or medications in terms of pain relief were minimal. This scenario seems to be an on individuals one for GP’s and patients alike. ████████ told me that subsequent to Ms Campbell’s death the practice had convened and discussed the circumstances and agreed on regular reviews for patients taking these sorts of medication. There were no plans identified to actively look for these patients and to work to rationalize and / or reduce their medications. I am of the view that polypharmacy including gabapentinoids and opiates represents a severe safety risk in patients with a iatrogenic drug dependency. I consider that the risk in individuals like Ms Campbell of an inadvertent overdose of medications which have a cumulative and synergistic effect to depress the central nervous system can easily become extreme and lead to death. There have been a number of deaths in the Milton Keynes, Bedfordshire and Luton areas related to concomitant use of high dose and combination gabapentinoids and opioids. ”
    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 Hilltops Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Severe risk of cumulative and synergistic central nervous system depression from gabapentinoid and opioid polypharmacy

    Wider context from the report

    “Her GP, ████████, gave clear and candid evidence. I accept the management of patients who describe intractable debilitating pain is challenging and difficult and that requests for other or increasing doses of medication can be difficult to resist. ████████ agreed that the prescribing of the various drugs identified had potential to be dangerous. He told me that after a certain point the benefits of increasing or adding doses or medications in terms of pain relief were minimal. This scenario seems to be an on individuals one for GP’s and patients alike. ████████ told me that subsequent to Ms Campbell’s death the practice had convened and discussed the circumstances and agreed on regular reviews for patients taking these sorts of medication. There were no plans identified to actively look for these patients and to work to rationalize and / or reduce their medications. I am of the view that polypharmacy including gabapentinoids and opiates represents a severe safety risk in patients with a iatrogenic drug dependency. I consider that the risk in individuals like Ms Campbell of an inadvertent overdose of medications which have a cumulative and synergistic effect to depress the central nervous system can easily become extreme and lead to death. There have been a number of deaths in the Milton Keynes, Bedfordshire and Luton areas related to concomitant use of high dose and combination gabapentinoids and opioids. ”
    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

    Audit high-dose opioid patients, arrange reviews, and consider dose reduction where appropriate.

    Verbatim wording from the response

    “2) In March 2022 we carried out an audit of patients on high dose opioids (> 120mg oral morphine equivalent) and arranged a review of these patients. We repeated this Audit in November- December 2022 and are currently in the process of redoing this audit and consideration given to dose reduction where appropriate.”

    Source location

    Response from Hilltop Surgery
    Page 1 · response
    Published 28 February 2023

    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

    Maintain three-monthly medication reviews using recall systems, preferably face to face and with a named clinician.

    Verbatim wording from the response

    “5) We are ensuring that these patients are reviewed 3 monthly, with robust recall systems in place, preferably face to face and with named clinician to review and rationalise the medication.”

    Source location

    Response from Hilltop Surgery
    Page 1 · response
    Published 28 February 2023

    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

    Identify and review patients prescribed opioids with gabapentinoids and benzodiazepines or Z-drugs.

    Verbatim wording from the response

    “4) We have identified other patients on combination of Opiates+Gabapentinoids+Benzodiazepines/Z-drugs who have now been reviewed.”

    Source location

    Response from Hilltop Surgery
    Page 1 · response
    Published 28 February 2023

    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

    Use the Arden’s Opioid Initiation and Monitoring template during medication reviews.

    Verbatim wording from the response

    “7) We have discussed and agreed that patients on a combination of Opiates+gabapentinoids+Benzodiazepines/Z drugs are reviewed 3 monthly and patients on high dose Opioids are reviewed 6 monthly. We agreed to use the Arden’s ‘Opioid Initiation and Monitoring’ template during the reviews to ensure all areas of review are covered.”

    Source location

    Response from Hilltop Surgery
    Page 1 · response
    Published 28 February 2023

    Open published response
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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