1 Feb 2024 Joy EBANKS · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1 Failure to review prolonged prescribing of dependency-forming drugs and formulate dosage-reduction plans View source
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
Action
Risk-score opioid and gabapentinoid patients, recall them for face-to-face structured medication reviews, and provide follow-up supporting safe dose reduction.
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Action
Update, externally review, approve and ratify the opioid and gabapentinoid prescribing policies.
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Action
Recruit a specialist prescribing pharmacist with pain-clinic experience to conduct structured medication reviews.
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Action
Train three in-house clinical pharmacists with the specialist pharmacist to develop their capability to conduct structured medication reviews.
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AI-generated summary
Joy EBANKS · 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
Joy Ebanks lived alone and was found unresponsive at home on 24 May 2023 after taking prescribed oxycodone and pregabalin for pain; she was pronounced deceased at the scene. The medical cause of death was oxycodone toxicity enhanced by pregabalin intake. The report raised concerns about very prolonged prescribing of two dependency-forming drugs, without evidence of a plan to reduce the dosages, and about the limited evidence for their long-term use in chronic pain.
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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 Kirby Road Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to review prolonged prescribing of dependency-forming drugs and formulate dosage-reduction plans
Wider context from the report “[1] There was evidence of very prolonged prescribing of two dependency forming drugs with no evidence to suggest that a discussion had been had or plan had been formulated to reduce the dosages .
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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 Risk-score opioid and gabapentinoid patients, recall them for face-to-face structured medication reviews, and provide follow-up supporting safe dose reduction.
Verbatim wording from the response “Our Clinical Lead Pharmacist identified, and risk scored all patients on opioid medications and also those on gabapentinoid medications to determine and recall individuals for a face-to-face structured medication review within a 28-day time period. These patients were then sent letters to inform them that their medication would be undergoing an upcoming review with a specialist prescribing pharmacist.” Source location Response from Kirby Road Surgery
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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 Update, externally review, approve and ratify the opioid and gabapentinoid prescribing policies.
Verbatim wording from the response “Our Opioid Prescribing Policy and our Gabapentinoid Prescribing Policy underwent updating and review by the Quality Assurance Manager to ensure all information was up to date. This was further reviewed by BLMK Medicines Management Matthew Davies to ensure compliance. Once recommended actions were implemented into policy, this was then signed off and ratified by” Source location Response from Kirby Road Surgery
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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 Recruit a specialist prescribing pharmacist with pain-clinic experience to conduct structured medication reviews.
Verbatim wording from the response “The Partners and Management Team sourced and recruited a specialist prescribing pharmacist (who has extensive experience of working in a pain clinic) to undertake the face-to-face structured medication reviews. Three of our inhouse clinical pharmacists are also undergoing training with our specialist prescribing pharmacist to enhance their skills and knowledge in this area to perform these reviews in the future.” Source location Response from Kirby Road Surgery
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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 Train three in-house clinical pharmacists with the specialist pharmacist to develop their capability to conduct structured medication reviews.
Verbatim wording from the response “The Partners and Management Team sourced and recruited a specialist prescribing pharmacist (who has extensive experience of working in a pain clinic) to undertake the face-to-face structured medication reviews. Three of our inhouse clinical pharmacists are also undergoing training with our specialist prescribing pharmacist to enhance their skills and knowledge in this area to perform these reviews in the future.” Source location Response from Kirby Road Surgery
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations