Concerns raised 5 Possible deficiencies in record keeping for Pregabalin prescriptions View source Failure to monitor Pregabalin for signs of abuse View source Serious Event Analysis failing to fully explore relevant risks View source Possible deficiencies in prescribing Pregabalin View source Failure to take required actions following risk analysis View source See 2 more concerns
Responses linked to these concerns
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AI-generated summary
Glenn Anthony LOCKWOOD · 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
Glenn Anthony Lockwood, a known drug user receiving opiate replacement treatment, was found unresponsive after a suspected overdose on 14 April 2023 and later suffered a cardiac arrest. Despite hospital treatment, he died on 2 June 2023; the inquest concluded that his death was drug related, with mixed drug toxicity recorded as the medical cause. Concerns included whether Pregabalin abuse risks were sufficiently monitored and whether prescribing and record-keeping issues had been fully investigated and addressed.
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 Limehouse Practice; that does not assign responsibility.
PFD Monitor interpretation Possible deficiencies in record keeping for Pregabalin prescriptions
Wider context from the report “(1) Mr Lockwood’s drug treatment provider wrote to his GP in August 2021 to advise caution “with regard to other medicines with potential for abuse.” According to the British National Formulary, Pregabalin should be monitored for “signs of abuse”. The evidence I received did not reassure me that sufficient steps were taken to monitor for signs of Pregabalin abuse, particularly in a patient with known history of drug abuse.
(2) The statement received from Mr Lockwood’s GP alluded to the fact that there were possible record keeping and prescribing issues surrounding Mr Lockwood’s prescriptions for Pregabalin. As a result, a Serious Event Analysis was conducted. In response to written queries from me, The Limehouse Practice responded by email on 14 November 2023. That email alluded to potential errors within the Serious Event Analysis and stated that the Serious Event Analysis would be re-opened and revisited. As such, I am not reassured that relevant risks have fully explored and/or any required action(s) taken.
” 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 Limehouse Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor Pregabalin for signs of abuse
Wider context from the report “(1) Mr Lockwood’s drug treatment provider wrote to his GP in August 2021 to advise caution “with regard to other medicines with potential for abuse.” According to the British National Formulary, Pregabalin should be monitored for “signs of abuse”. The evidence I received did not reassure me that sufficient steps were taken to monitor for signs of Pregabalin abuse , particularly in a patient with known history of drug abuse .
(2) The statement received from Mr Lockwood’s GP alluded to the fact that there were possible record keeping and prescribing issues surrounding Mr Lockwood’s prescriptions for Pregabalin. As a result, a Serious Event Analysis was conducted. In response to written queries from me, The Limehouse Practice responded by email on 14 November 2023. That email alluded to potential errors within the Serious Event Analysis and stated that the Serious Event Analysis would be re-opened and revisited. As such, I am not reassured that relevant risks have fully explored and/or any required action(s) taken.
” 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 Limehouse Practice; that does not assign responsibility.
PFD Monitor interpretation Serious Event Analysis failing to fully explore relevant risks
Wider context from the report “(1) Mr Lockwood’s drug treatment provider wrote to his GP in August 2021 to advise caution “with regard to other medicines with potential for abuse.” According to the British National Formulary, Pregabalin should be monitored for “signs of abuse”. The evidence I received did not reassure me that sufficient steps were taken to monitor for signs of Pregabalin abuse, particularly in a patient with known history of drug abuse.
(2) The statement received from Mr Lockwood’s GP alluded to the fact that there were possible record keeping and prescribing issues surrounding Mr Lockwood’s prescriptions for Pregabalin. As a result, a Serious Event Analysis was conducted. In response to written queries from me, The Limehouse Practice responded by email on 14 November 2023. That email alluded to potential errors within the Serious Event Analysis and stated that the Serious Event Analysis would be re-opened and revisited. As such, I am not reassured that relevant risks have fully explored and/or any required action(s) taken.
” 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 Limehouse Practice; that does not assign responsibility.
PFD Monitor interpretation Possible deficiencies in prescribing Pregabalin
Wider context from the report “(1) Mr Lockwood’s drug treatment provider wrote to his GP in August 2021 to advise caution “with regard to other medicines with potential for abuse.” According to the British National Formulary, Pregabalin should be monitored for “signs of abuse”. The evidence I received did not reassure me that sufficient steps were taken to monitor for signs of Pregabalin abuse, particularly in a patient with known history of drug abuse.
(2) The statement received from Mr Lockwood’s GP alluded to the fact that there were possible record keeping and prescribing issues surrounding Mr Lockwood’s prescriptions for Pregabalin . As a result, a Serious Event Analysis was conducted. In response to written queries from me, The Limehouse Practice responded by email on 14 November 2023. That email alluded to potential errors within the Serious Event Analysis and stated that the Serious Event Analysis would be re-opened and revisited. As such, I am not reassured that relevant risks have fully explored and/or any required action(s) taken.
” 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 Limehouse Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to take required actions following risk analysis
Wider context from the report “(1) Mr Lockwood’s drug treatment provider wrote to his GP in August 2021 to advise caution “with regard to other medicines with potential for abuse.” According to the British National Formulary, Pregabalin should be monitored for “signs of abuse”. The evidence I received did not reassure me that sufficient steps were taken to monitor for signs of Pregabalin abuse, particularly in a patient with known history of drug abuse.
(2) The statement received from Mr Lockwood’s GP alluded to the fact that there were possible record keeping and prescribing issues surrounding Mr Lockwood’s prescriptions for Pregabalin. As a result, a Serious Event Analysis was conducted. In response to written queries from me, The Limehouse Practice responded by email on 14 November 2023. That email alluded to potential errors within the Serious Event Analysis and stated that the Serious Event Analysis would be re-opened and revisited. As such, I am not reassured that relevant risks have fully explored and/or any required action(s) taken .
” 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 Document medication dose or tablet-strength changes and notify patients of those changes.
Verbatim wording from the response “3. If any changes are made in doses of medication or tablet strength, this must be documented in EMIS consultation notes so there is a clearly identifiable rationale for any change. Patients should also be notified of any change in drug dosage / tablet strength.” Source location Response from The Limehouse 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 Review identified patients’ medication and discuss with RESET whether it should prescribe their opiate substitute and other dependence-potential medicines.
Verbatim wording from the response “2. We are carrying out a search to identify all patients on Pregabalin/diazepam or similar medications who are also prescribed opiate substitute treatment, either at RESET or in shared care. We will carry out a medication review for those patients and discuss with RESET and” Source location Response from The Limehouse 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 Provide all prescribers with refresher training on EMIS medication history and prescribing dependence-potential medicines.
Verbatim wording from the response “4. Protected Learning Time is to be used to provide refresher training to all prescribers about EMIS prescribing function and how to view previous medication issues / amendments, as well as further training on prescribing drugs with potential for dependence. I have contacted the CGL/RESET consultant and am awaiting a response from them about agreeing a date for training.” Source location Response from The Limehouse 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 Introduce three-monthly face-to-face reviews for patients prescribed dependence-inducing medicines, including Pregabalin, gabapentin, benzodiazepines and oxycodone.
Verbatim wording from the response “1. We will ensure 3 monthly face to face reviews for patients on Pregabalin, gabapentin, benzodiazepines, oxycodone and other dependence inducing medications.” Source location Response from The Limehouse 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 Pregabalin dose was within BNF ranges and prescribed for a licensed indication, making the increase a reasonable response to reported anxiety.
Verbatim wording from the response “In December 2022 Mr Lockwood was reviewed and he reported increased anxiety symptoms. The GP suggested this dose increase as a response to Mr Lockwood’s reported increased anxiety. The dose is within the BNF recommended ranges, and this medication was prescribed for anxiety, one of the licenced indications for this drug. This does therefore seem a reasonable course of action. That doctor reduced the length of the prescription to two weeks instead of the usual four weeks.” Source location Response from The Limehouse 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 Practice could not arrange a timely SEA because it received no hospital notification or medical cause of death until after the inquest.
Verbatim wording from the response “Unfortunately, we did not receive any further information from the hospital or notification of Mr Lockwood’s death until a letter dated 30 June 2023 was received from the Senior Coroner’s officer on 3 July 2023. At that stage we were unaware of the medical cause of death to allow us to consider arranging for an SEA to be carried out. We only received details of the medical cause of death following the conclusion of the inquest. We have taken steps to ensure that requests for reports and correspondence with the Coroner’s office are brought to the attention of the partners so that we can ensure that all matters relevant to the Coroner’s investigation and inquiry are dealt with and that, where appropriate, we can arrange for an SEA to be undertaken in a timely manner.” Source location Response from The Limehouse 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 There had been no previous early requests or concerns about Pregabalin misuse before the mistaken early-request concern arose.
Verbatim wording from the response “Until December 2022, Mr Lockwood continued to receive prescriptions for Pregabalin at four weekly intervals when the duration was changed to two weekly. There had been no previous incidences of early requesting of Pregabalin, or concerns that the patient was misusing or over-using this medication.” Source location Response from The Limehouse Practice
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations