Recipient

Hopwood House Medical Practice

First report 10 Jun 2019•Latest report 10 Jun 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: 1
Published responses: 100%
Concerns addressed: 4
Stated actions: 5

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

5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

10 Jun2019
Manchester North
Concerns raised4
1. Failure to communicate clinically significant butane gas use and consumption amount to the GP practice
2. Failure to transfer the full medical records and past medical history to the new substance misuse service
3. Failure to conduct a full review of all prescribed medications
1. Failure to respond to and action clinical information requests from the substance misuse service
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Implement a DNA policy requiring discussion of missed appointments and selection of an appropriate patient-contact method.
  Stated completed
2. Action
  Provide feedback to the locum doctor about the inadequacy of the medication review.
  Stated planned
3. Action
  Use the electronic Butane-misuse code on patients’ problem lists in future.
  Stated planned
1. Action
  Maintain heightened vigilance in communication, correspondence and medication reviews, particularly for sedatives, chronic pain medication, methadone and substance misuse.
  Stated in progress
2. Action
  Employ a clinical pharmacist to undertake complicated medication reviews and support practice workload.
  Stated planned
Respondent positions 2
1. Position
  The commissioned provider is responsible for resolving transfer of full records when a new provider takes over.
  Redirects responsibility
1. Position
  A joint learning meeting with Turning Point would occur only if Oldham CCG supported it.
  Unable to act
AI-generated summary

Beverley Shaw · 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

Beverley Shaw was found deceased in her bed at home in Oldham in the early hours of 11 December 2018. The inquest heard that she had multiple prescribed medicines, was receiving methadone, and was using cocaine and butane gas. Concerns included inadequate communication between the substance misuse service and GP practice about her butane gas use, lack of a full medication review, and incomplete transfer of medical records.

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 Hopwood House Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate clinically significant butane gas use and consumption amount to the GP practice
Wider context from the report
“○ There was a lack of communication between Turning Point and the GP practice specifically in respect of Ms Shaw’s use of butane gas. There was no information contained in the evidence before the Court to indicate her GP was aware of the use of butane gas, which was significant (ie 5 cans a day). This was described in evidence by Turning Point as her most significant addiction which was not amenable to treatment with medication. There was one 4 page letter dated the 15th May 2018 from Turning Point to the GP practice, in the summary section this simply recorded, “Uses butane gas daily.” In the section headed “Current Reported Substance Use” there is no mention of butane gas. The remainder of this letter deals with other matters. No information was shared with the GP with regards to the amount of gas being used by Ms Shaw. ”
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 Hopwood House Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to transfer the full medical records and past medical history to the new substance misuse service
Wider context from the report
“○ The Court heard evidence that following the transition from another provider to Turning Point a decision was taken that all medical records relating to users of the substance misuse service do not need to be carried over to Turning Point. Unlike other medical records ie GP records which go with the patient when they move surgery the new substance misuse service only receives the last 6 months records hence they do not have the full past medical history available. ”
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 Hopwood House Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct a full review of all prescribed medications
Wider context from the report
“○ A medication review took place in the GP practice in August 208, this only documented a review of her olanzapine medication and the fact that she was in receipt of methadone and using cocaine. There is no evidence that there was a full review of all the medications prescribed to Ms Shaw. When questioned it was accepted in Court it was unclear as to why she was still being prescribed a number of medications. ”
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 Hopwood House Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to respond to and action clinical information requests from the substance misuse service
Wider context from the report
“○ There is no record of a response from the GP practice to Turning Point following their letter dated the 15th May 2018. This had a number of requests for actions by the GP including the sharing of any blood results (LFT, FC and U&E), together with information confirming whether there was any blood disorders of drugs which may interact with methadone. There was no evidence that this information was shared or actioned. ”
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
Implement a DNA policy requiring discussion of missed appointments and selection of an appropriate patient-contact method.

Verbatim wording from the response
“Since the inquest we have as a practice reflected on Beverley’s death and have discussed what we could have done differently to prevent her death. We noticed that in her records she had many failed appointments (DNAs) and possibly not fully engaged with clinicians about her health. In April 2019 we put together a DNA policy. The policy outlines that patients who DNA shall be discussed in the practice meeting and a suitable method of contacting the patient should be sought. On reflection with this patient if we had done this, Miss Shaw could have been referred to the Focus Care worker linked to our practice and she would have had a home visit assessment. From this we may have been made aware of the extent of her Butane abuse and this could have been communicated to the clinicians and Turning Point.”

Source location
2019-0191-Response-by-Hopwood-House-Medical-Practice
Page 1 · response
Published 23 August 2019
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
Provide feedback to the locum doctor about the inadequacy of the medication review.

Verbatim wording from the response
“The last medication review was done by one of our regular locum doctors who has been working at the practice for the last 3 years. From the practice meeting we concluded that the medication review was sub-adequate and the lead GP of the practice will feed this back to him. However, given the time limits and pressures in primary care, and the inconsistencies of CCG employed pharmacists, the practice has made a decision to employ a clinical pharmacist do complicated medication reviews and help with the workload. Despite this, as highlighted already by the letter from the 15th May 2018 sent by ████████ (Consultant Psychiatrist), they have a clear accurate record of Miss Shaw’s medication and any drug interactions that may have been overlooked by the practice, perhaps should have been double checked then.”

Source location
2019-0191-Response-by-Hopwood-House-Medical-Practice
Page 2 · response
Published 23 August 2019
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 electronic Butane-misuse code on patients’ problem lists in future.

Verbatim wording from the response
“We also found the electronic code “Misuse of Butane EMISNQM197”. That we will use in future to code this on the Problem List.”

Source location
2019-0191-Response-by-Hopwood-House-Medical-Practice
Page 2 · response
Published 23 August 2019
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 heightened vigilance in communication, correspondence and medication reviews, particularly for sedatives, chronic pain medication, methadone and substance misuse.

Verbatim wording from the response
“I note that there were several opportunities where she could have had some of her chronic pain medication reduced. However these were missed. Again this will be avoided in future when a clinical pharmacist is employed by the practice and can go through complicated medication reviews. The GPs in the practice are aware of this as a significant event and will be mindful of patients on sedatives, chronic pain medication with methadone and substance abuse.”

Source location
2019-0191-Response-by-Hopwood-House-Medical-Practice
Page 3 · response
Published 23 August 2019
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
Employ a clinical pharmacist to undertake complicated medication reviews and support practice workload.

Verbatim wording from the response
“The last medication review was done by one of our regular locum doctors who has been working at the practice for the last 3 years. From the practice meeting we concluded that the medication review was sub-adequate and the lead GP of the practice will feed this back to him. However, given the time limits and pressures in primary care, and the inconsistencies of CCG employed pharmacists, the practice has made a decision to employ a clinical pharmacist do complicated medication reviews and help with the workload. Despite this, as highlighted already by the letter from the 15th May 2018 sent by ████████ (Consultant Psychiatrist), they have a clear accurate record of Miss Shaw’s medication and any drug interactions that may have been overlooked by the practice, perhaps should have been double checked then.”

Source location
2019-0191-Response-by-Hopwood-House-Medical-Practice
Page 2 · response
Published 23 August 2019
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 commissioned provider is responsible for resolving transfer of full records when a new provider takes over.

Verbatim wording from the response
“Records This is related to the commissioned provider and I hope that they can resolve this issue with the transfer of full records with a new provider.”

Source location
2019-0191-Response-by-Hopwood-House-Medical-Practice
Page 3 · response
Published 23 August 2019
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
A joint learning meeting with Turning Point would occur only if Oldham CCG supported it.

Verbatim wording from the response
“The practice would also, if supported through Oldham CCG have a meeting with Turning Point separately as a learning event to see what further changes we can both make to make sure miscommunications are avoided in the future”

Source location
2019-0191-Response-by-Hopwood-House-Medical-Practice
Page 4 · response
Published 23 August 2019
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 communicate clinically significant butane gas use and consumption amount to the GP practice

Failure to transfer the full medical records and past medical history to the new substance misuse service

Failure to conduct a full review of all prescribed medications

Failure to respond to and action clinical information requests from the substance misuse service

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.5

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 5

Respondent positions 2