Summary
Trends
Evidence
Reports, concerns and published responses Receiving a report does not make the recipient responsible for every concern in it. PFD Monitor does not verify whether stated actions happened.
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 0% Found for named reports
Concerns addressed 0 Across all linked responses
Stated actions 0 Described in responses
Concerns raised 2 Failure to report prescribed medication non-collection directly to the designated Key Worker View source Failure of the medication non-collection reporting threshold to identify concerns after one or two missed daily collections for reliably compliant patients View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Paul Geoffrey Mullen · 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
Paul Geoffrey Mullen died at his home in Wigan on 22 June 2017. He had been receiving daily methadone but did not collect it for three consecutive days before his death. The report raised concerns that the pharmacy’s failure to report the missed collections promptly to his designated Key Worker, and the three-day reporting threshold, may have delayed checks on his welfare.
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 Hindley Health Centre Pharmacy; that does not assign responsibility.
PFD Monitor interpretation Failure to report prescribed medication non-collection directly to the designated Key Worker
Wider context from the report “1. During the Inquest evidence was heard that:-
i. The deceased was receiving a daily prescription of methadone to be collected and administered on a daily basis from the Pharmacy. The prescriptions were not collected from the Pharmacy on Monday the 18th June 2017, Tuesday the 19th June 2017 and Wednesday the 20th June 2017.
ii. There is a system, referred to at the Inquest as a “red flag system”, for a pharmacy to report the non-collection of a prescription of methadone when a patient has not collected the medication on three consecutive occasions. The evidence at the Inquest indicated that the purpose of the report by a pharmacy of non-collection is to enable the Key Worker to be made aware of the non-collection of the medication so that the Key Worker could take appropriate action to contact the patient and to check whether any concerns need to be addressed.
iii. The Key Worker attached to the deceased was ████████, who is a Key Worker employed by Addiction, and she gave evidence that the procedure relating to the deceased, and other patients, to report non-collection of medication is for the report to be sent by a pharmacy to GMMH and not directly to the Key Worker . In the case of the deceased, ████████, the deceased’s Key Worker, did not receive a report that the deceased had not collected his methadone on the above dates and she only became aware of his non-collection of methadone by her own enquiry when she telephoned the Pharmacy to request that the prescription of methadone be placed on hold.
iv. ████████ also gave evidence that some patients, particularly those patients who are known to be diligent and to collect their medication on time each and every day, may require a report of non-collection of medication earlier than three days because, in relation to those patients, a single failure to collect medication may raise concerns and require enquiries by the Key Worker as to any concerns, in view of the fact that those patients always collect their medication each and every day.
v. GMMH is a Mental Health NHS Foundation Trust and is separate in terms of governance, even though working in partnership to an extent, from Addiction, which is described as a Drug, Alcohol and Mental Health Treatment Charity. Accordingly, any report relating to the non-collection of medication addressed to GMMH requires a further onward report from GMMH to Addiction . The governance of GMMH has no control over Practitioners employed by Addiction and GMMH and Addiction do not share computer reporting systems.
” 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 Hindley Health Centre Pharmacy; that does not assign responsibility.
PFD Monitor interpretation Failure of the medication non-collection reporting threshold to identify concerns after one or two missed daily collections for reliably compliant patients
Wider context from the report “1. During the Inquest evidence was heard that:-
i. The deceased was receiving a daily prescription of methadone to be collected and administered on a daily basis from the Pharmacy. The prescriptions were not collected from the Pharmacy on Monday the 18th June 2017, Tuesday the 19th June 2017 and Wednesday the 20th June 2017.
ii. There is a system, referred to at the Inquest as a “red flag system”, for a pharmacy to report the non-collection of a prescription of methadone when a patient has not collected the medication on three consecutive occasions . The evidence at the Inquest indicated that the purpose of the report by a pharmacy of non-collection is to enable the Key Worker to be made aware of the non-collection of the medication so that the Key Worker could take appropriate action to contact the patient and to check whether any concerns need to be addressed.
iii. The Key Worker attached to the deceased was ████████, who is a Key Worker employed by Addiction, and she gave evidence that the procedure relating to the deceased, and other patients, to report non-collection of medication is for the report to be sent by a pharmacy to GMMH and not directly to the Key Worker. In the case of the deceased, ████████, the deceased’s Key Worker, did not receive a report that the deceased had not collected his methadone on the above dates and she only became aware of his non-collection of methadone by her own enquiry when she telephoned the Pharmacy to request that the prescription of methadone be placed on hold.
iv. ████████ also gave evidence that some patients, particularly those patients who are known to be diligent and to collect their medication on time each and every day, may require a report of non-collection of medication earlier than three days because, in relation to those patients, a single failure to collect medication may raise concerns and require enquiries by the Key Worker as to any concerns, in view of the fact that those patients always collect their medication each and every day.
v. GMMH is a Mental Health NHS Foundation Trust and is separate in terms of governance, even though working in partnership to an extent, from Addiction, which is described as a Drug, Alcohol and Mental Health Treatment Charity. Accordingly, any report relating to the non-collection of medication addressed to GMMH requires a further onward report from GMMH to Addiction. The governance of GMMH has no control over Practitioners employed by Addiction and GMMH and Addiction do not share computer reporting systems.
” Open source report
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· Data reviewed 7 Sep 2026 · About data quality and limitations
Data last updated 7 September 2026
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations