10 Jun 2019 Beverley Shaw · Prevention of Future Deaths report Manchester North
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Concerns raised 4 Failure to communicate clinically significant butane gas use and consumption amount to the GP practice View source Failure to transfer the full medical records and past medical history to the new substance misuse service View source Failure to conduct a full review of all prescribed medications View source Failure to respond to and action clinical information requests from the substance misuse service View source See 1 more concern
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
Action
Implement a DNA policy requiring discussion of missed appointments and selection of an appropriate patient-contact method.
View source
Action
Provide feedback to the locum doctor about the inadequacy of the medication review.
View source
Action
Use the electronic Butane-misuse code on patients’ problem lists in future.
View source
Action
Maintain heightened vigilance in communication, correspondence and medication reviews, particularly for sedatives, chronic pain medication, methadone and substance misuse.
View source
Action
Employ a clinical pharmacist to undertake complicated medication reviews and support practice workload.
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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.
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× 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
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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
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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
Open published response
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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
Open published response
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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
Open published response
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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
Open published response
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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
Open published response
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations