Concerns raised 5 Lack of procedures to monitor and manage repeat prescriptions exceeding prescribed dosages View source Lack of procedures to manage access to medication amounts exceeding prescribed quantities View source Lack of procedures to fully explore drug regimens and alternative pain management at annual medication reviews View source Failure to discuss with patients the implications of exceeding prescribed dosages View source Failure to record discussions about exceeding prescribed dosages View source See 2 more concerns
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. 7
Action
Change repeat-prescribing policy for all medicines and implement amended repeat-prescribing and acute-prescribing protocols with strengthened electronic prompts and consultation processes.
View source
Action
Identify patients prescribed tramadol and other potentially harmful medicines, review prescribing indications, doses and issue patterns, and recommend contact, early review or no change.
View source
Action
Call patients identified as potential over-users of tramadol for early review.
View source
Action
Complete a thorough review of medication ordering and review procedures to identify safety problems.
View source
Action
Explain the amended prescribing protocols and procedures to all practice staff during protected time within 10 days.
View source
Action
Convert electronic prescriptions to paper prescriptions requiring doctor review before signing.
View source
Action
Seek medicines-management, drugs-and-alcohol, and pharmacist input on difficult or potentially problematic prescriptions.
View source See 4 more actions
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AI-generated summary
Craig Stuart Hamilton · 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
Craig Stuart Hamilton died on 8 December 2016 from acute tramadol toxicity after taking excess Tramadol to relieve chronic pain and sleep before working the next day. The principal concerns were the absence of clear procedures for managing patients who obtain or take more medication than prescribed, and insufficient exploration of medication regimes, alternative pain management, and discussions about exceeding prescribed dosages.
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 Manor Field Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures to monitor and manage repeat prescriptions exceeding prescribed dosages
Wider context from the report “(2) Absence of clear procedures to monitor and manage patients who endeavour to obtain repeat prescriptions such that it takes them beyond the prescribed dosages .
” 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 Manor Field Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures to manage access to medication amounts exceeding prescribed quantities
Wider context from the report “(1) Absence of clear procedures to manage patients who routinely access larger amounts of medication than actually prescribed .
” 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 Manor Field Surgery; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures to fully explore drug regimens and alternative pain management at annual medication reviews
Wider context from the report “(3) Absence of clear procedures to fully explore drug regimes and alternative forms of pain management at annual medication reviews .
” 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 Manor Field Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss with patients the implications of exceeding prescribed dosages
Wider context from the report “(4) Consideration for improved systems for discussing with patients the implications of them attempting to exceed prescribed dosages and recording that such discussions have taken place.
” 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 Manor Field Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to record discussions about exceeding prescribed dosages
Wider context from the report “(4) Consideration for improved systems for discussing with patients the implications of them attempting to exceed prescribed dosages and recording that such discussions have taken place .
” 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 Change repeat-prescribing policy for all medicines and implement amended repeat-prescribing and acute-prescribing protocols with strengthened electronic prompts and consultation processes.
Verbatim wording from the response “Since this incident our practice attitude has changed. We have changed our policy for repeat prescribing of all medication, not just tramadol.” Source location 2017-0197-Response-by-Manor-Field-Surgery
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 Identify patients prescribed tramadol and other potentially harmful medicines, review prescribing indications, doses and issue patterns, and recommend contact, early review or no change.
Verbatim wording from the response “We took immediate action on the afternoon of the request to identify the patients being prescribed tramadol and extended the search to other medicines with the potential for self-harm. All electronic prescriptions were changed to paper format and passed to the doctors for review before signing. All names of patients identified were passed to one of the partners to perform a review of the computer notes and make a recommendation. The inspection included
* the indication for the medicine
* the recommended dose on the prescription
* the recent historical issue pattern” Source location 2017-0197-Response-by-Manor-Field-Surgery
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 Call patients identified as potential over-users of tramadol for early review.
Verbatim wording from the response “The search showed that 79 of our 90 patients taking tramadol were not abusing the drug. Action has been taken to limit the potential over-users by calling them in for early review.” Source location 2017-0197-Response-by-Manor-Field-Surgery
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 Complete a thorough review of medication ordering and review procedures to identify safety problems.
Verbatim wording from the response “We have discovered that our procedures for issue and review of medication were not satisfactory.” Source location 2017-0197-Response-by-Manor-Field-Surgery
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 Explain the amended prescribing protocols and procedures to all practice staff during protected time within 10 days.
Verbatim wording from the response “The enclosed protocols have been examined by GP partners and practice manager. I am to explain to all staff in the practice, in protected time, the changes within 10 days.” Source location 2017-0197-Response-by-Manor-Field-Surgery
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 Convert electronic prescriptions to paper prescriptions requiring doctor review before signing.
Verbatim wording from the response “We took immediate action on the afternoon of the request to identify the patients being prescribed tramadol and extended the search to other medicines with the potential for self-harm. All electronic prescriptions were changed to paper format and passed to the doctors for review before signing. All names of patients identified were passed to one of the partners to perform a review of the computer notes and make a recommendation. The inspection included
* the indication for the medicine
* the recommended dose on the prescription
* the recent historical issue pattern” Source location 2017-0197-Response-by-Manor-Field-Surgery
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 Seek medicines-management, drugs-and-alcohol, and pharmacist input on difficult or potentially problematic prescriptions.
Verbatim wording from the response “We have met several times as partners. We have sought advice from the Clinical Commissioning Group, particularly the Medicines Management Team. We asked the Drugs and Alcohol Team for advice and assistance in dealing with more difficult cases. Our local pharmacist was alerted to the problem and invited to provide information on prescriptions his team thought problematic.” Source location 2017-0197-Response-by-Manor-Field-Surgery
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations