Recipient

Hilltops Medical Centre

First report 22 Feb 2023•Latest report 22 Feb 2023

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: 2
Stated actions: 9

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

9stated actions described

Topic comparisons are not available in the current evidence snapshot.

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.

22 Feb2023
Milton Keynes
Concerns raised2
1. Failure to actively identify patients taking high-risk medication combinations and rationalize or reduce their medications
2. Severe risk of cumulative and synergistic central nervous system depression from gabapentinoid and opioid polypharmacy
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
  Audit high-dose opioid patients, arrange reviews, and consider dose reduction where appropriate.
  Stated in progress
2. Action
  Maintain three-monthly medication reviews using recall systems, preferably face to face and with a named clinician.
  Stated in progress
3. Action
  Identify and review patients prescribed opioids with gabapentinoids and benzodiazepines or Z-drugs.
  Stated completed
1. Action
  Use the Arden’s Opioid Initiation and Monitoring template during medication reviews.
  Stated planned
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

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 raised2

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

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

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

Actions described in response 4