Recipient

Macklin Street Surgery

First report 25 Nov 2024•Latest report 25 Nov 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
Published responses: 100%
Concerns addressed: 1
Stated actions: 9

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

25 Nov2024
Derby and Derbyshire
Concerns raised1
1. Lack of measures to prevent excess prescribing to patients at risk of overdose during longer bank holiday periods
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Seek advice from the Integrated Care Board on using central clinical pharmacy and medicines-management expertise for high-risk patients.
  Stated planned
2. Action
  Review short-term-prescription patients clinically and classify their risk of medication harm, with reassessment at annual medication reviews.
  Stated in progress
3. Action
  Conduct a significant event analysis to identify safer arrangements for short-term prescriptions around bank holidays.
  Stated completed
1. Action
  Split high-risk patients’ prescriptions into shorter supplies when specified bank holidays fall on Tuesday.
  Stated planned
2. Action
  Implement rolling alerts notifying clinicians when patients move onto short-term prescriptions.
  Stated in progress
3. Action
  Move all short-term prescription issue days to Tuesday, notify patients and pharmacies, and place alerts in patient notes.
  Stated completed
Respondent positions 2
1. Position
  Addressing digital reporting constraints requires action by the national system supplier and NHS Digital.
  Redirects responsibility
1. Position
  Risk cannot be mitigated entirely because pharmacies are not routinely open on bank holidays and patients may choose different pharmacies.
  Unable to act
AI-generated summary

Margaret Mary Feeney · 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

Margaret Mary Feeney was found deceased at home after taking excess prescribed medication, with pneumonia also contributing to her death. The principal concern was that prescribing and pharmacy arrangements around longer bank holiday periods allowed excess medication to be supplied to a patient recognised as being at risk of overdose.

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 Macklin Street Surgery; that does not assign responsibility.
PFD Monitor interpretation
Lack of measures to prevent excess prescribing to patients at risk of overdose during longer bank holiday periods
Wider context from the report
“I am concerned that measures are not in place at Macklin Street Surgery and Daynight pharmacy to prevent prescription of excess medication to patient’s recognised to be at risk of overdose, either intentional or unintentional, who are ordinarily issued shorter period repeat prescriptions to reduce those risks. This situation arises when early prescriptions are issued due to statutory holiday periods when most pharmacies are likely to be closed. I have been informed that measures have been introduced to prevent excess prescribing by taking account of single day bank holidays, but there are no measures relating to longer bank holiday periods (e.g. Easter). With electronic patient record and data systems it seems a reasonable presumption that suitable solutions can be identified. ”
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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
Seek advice from the Integrated Care Board on using central clinical pharmacy and medicines-management expertise for high-risk patients.

Verbatim wording from the response
“The surgery will write to the Integrated Care Board seeking advice on how we use the ICB system's central clinical pharmacy / medicines management expertise to assist practices with the management of high-risk patients. We will liaise with the Integrated Care Board to determine how our learning from this experience could be shared with other local GP surgeries to assist them in improving their processes around short-term prescribing. We will also highlight to the ICB any potential national level digital constraints.”

Source location
Response from Macklin Street Surgery
Page 3 · response
Published 27 November 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
Review short-term-prescription patients clinically and classify their risk of medication harm, with reassessment at annual medication reviews.

Verbatim wording from the response
“The surgery is currently in the process of ensuring that the notes of all of the patients who have been identified as being on short-term prescriptions are reviewed by a clinician to assess whether each patient is at high or low risk. However, risk is broader than risk of overuse / overdose. Risk includes risk of medication harm, (that is to say, some drugs would present a greater risk of harm than others if overused or taken in overdose). Therefore, a clinician will determine whether a patient is at high or low risk of harm if the patient takes more than their prescribed dose. This will be reviewed at the annual medication review.”

Source location
Response from Macklin Street Surgery
Page 2 · response
Published 27 November 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
Conduct a significant event analysis to identify safer arrangements for short-term prescriptions around bank holidays.

Verbatim wording from the response
“In light of Mrs Feeney’s death, the practice conducted a significant event analysis on 8 August 2024 and a copy of that report has been shared with you previously. As part of that review, it was identified that a way of minimising the need to bring forward 7-day prescriptions prior to bank holidays (and therefore reduce the risks associated with patients having additional medication) was to move the day on which 7-day prescriptions were issued. We initially considered changing the issuing day to a Wednesday but we have since decided to move the day of issue to a Tuesday.”

Source location
Response from Macklin Street Surgery
Page 2 · response
Published 27 November 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
Split high-risk patients’ prescriptions into shorter supplies when specified bank holidays fall on Tuesday.

Verbatim wording from the response
“Now that all short-term prescriptions have been moved to a Tuesday, the issue of having to alter prescription processes will only arise on the years when Christmas Day, Boxing Day or New Year’s Day fall on a Tuesday. If Christmas Day, Boxing Day or New Year’s Day fall on a Tuesday, the prescriptions for those patients who have been identified by a clinician as being at high risk will be split i.e. the prescription week will be divided so that those patients will receive two shorter prescriptions to cover them for the bank holiday. How the prescription will be split will depend on how the bank holiday falls but could take a 3:4 day format thus minimising the risks as far as possible.”

Source location
Response from Macklin Street Surgery
Page 2 · response
Published 27 November 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
Implement rolling alerts notifying clinicians when patients move onto short-term prescriptions.

Verbatim wording from the response
“The surgery has now identified all patients who are on short-term prescriptions (which we have defined as having a prescribing period of 14 days or less) and the prescription day for all of these patients has been moved to a Tuesday. Patients and pharmacies have been advised. An alert has also been placed in the patients' notes. We are implementing a rolling alert so that a clinician will be alerted if a patient moves onto short-term prescriptions in the future.”

Source location
Response from Macklin Street Surgery
Page 2 · response
Published 27 November 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
Move all short-term prescription issue days to Tuesday, notify patients and pharmacies, and place alerts in patient notes.

Verbatim wording from the response
“In light of Mrs Feeney’s death, the practice conducted a significant event analysis on 8 August 2024 and a copy of that report has been shared with you previously. As part of that review, it was identified that a way of minimising the need to bring forward 7-day prescriptions prior to bank holidays (and therefore reduce the risks associated with patients having additional medication) was to move the day on which 7-day prescriptions were issued. We initially considered changing the issuing day to a Wednesday but we have since decided to move the day of issue to a Tuesday.”

Source location
Response from Macklin Street Surgery
Page 2 · response
Published 27 November 2024
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
Addressing digital reporting constraints requires action by the national system supplier and NHS Digital.

Verbatim wording from the response
“Unfortunately, it is not possible for the surgery to mitigate risk entirely because of the fact that pharmacies are not routinely open 7 days a week including on all bank holidays and because patients, understandably, have the freedom to choose which pharmacy they would like their prescriptions sent to. As you have identified, this is not an issue that is likely limited to Macklin Street Surgery but is one that is likely to affect all GP surgeries across the country. It should also be appreciated that there are some technical constraints to the digital records system the practice uses (SystmOne) and the reports it is able to generate.”

Source location
Response from Macklin Street Surgery
Page 2 · response
Published 27 November 2024
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
Risk cannot be mitigated entirely because pharmacies are not routinely open on bank holidays and patients may choose different pharmacies.

Verbatim wording from the response
“Unfortunately, it is not possible for the surgery to mitigate risk entirely because of the fact that pharmacies are not routinely open 7 days a week including on all bank holidays and because patients, understandably, have the freedom to choose which pharmacy they would like their prescriptions sent to. As you have identified, this is not an issue that is likely limited to Macklin Street Surgery but is one that is likely to affect all GP surgeries across the country. It should also be appreciated that there are some technical constraints to the digital records system the practice uses (SystmOne) and the reports it is able to generate.”

Source location
Response from Macklin Street Surgery
Page 2 · response
Published 27 November 2024
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 raised1

Lack of measures to prevent excess prescribing to patients at risk of overdose during longer bank holiday periods

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.6

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 6

Respondent positions 2