Recipient

Kirby Road Surgery

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First report 1 Feb 2024•Latest report 1 Feb 2024

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

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
9

Described in responses

Reports over time

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 Kirby Road Surgery linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Bedfordshire and Luton

    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.

    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 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. ”
    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

    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
    Page 2 · response
    Published 8 January 2024

    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

    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
    Page 2 · response
    Published 8 January 2024

    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

    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
    Page 2 · response
    Published 8 January 2024

    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

    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
    Page 2 · response
    Published 8 January 2024

    Open published response
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
67%22%11%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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