NHS Brighton and Hove Clinical Commissioning Group

Health and care · Clinical commissioning group

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First report 19 Feb 2016•Latest report 15 Jun 2018

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from NHS Brighton and Hove Clinical Commissioning Group linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Brighton and Hove

    AI-generated summary

    Darren James CARRINGTON · 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

    Darren James CARRINGTON died after collapsing with a fatal level of Zopiclone in his blood and did not recover. The inquest concluded that the death was misadventure, being an impulsive overdose while under the influence of alcohol. Concerns included the prescribing of potentially dependency-forming medication, excessive Zopiclone prescribing over 57 days, and the ability of receptionists and clinicians to override computer warnings and other safeguards.

    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 NHS Brighton and Hove Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to apply adequate safeguards when prescribing potentially dependence-forming or misused medication

    Wider context from the report

    “The method of prescribing medication such as Zopiclone (in this case), Codeine, Morphine, Benzodiazepines etc. to patients which suggests that they either are or are very likely to be becoming dependent upon such medications or are misusing them. Examples of both the above would be too frequent requests for repeat prescriptions and information concerning a history of overdoses. The Inquest discussed whether circumstances, including those outlined above should trigger an automatic/mandatory medication review conducted with the patient; consideration of a different prescribing period and very careful monitoring of the online requests for repeat prescriptions. Alternatively, there could be a ban on the requests for repeat prescriptions with the repeats simply being issued for an appropriate period of time “automatically”. In this case as you will see from ████████ report, over twice the appropriate amount of Zopiclone was issued over a period of 57 days. The patient in question had Zopiclone present at a fatal level in his blood at the time of his collapse from which he never recovered. I remain very worried about these prescribing issues and about the fact that apparently receptionists and clinicians can override the warnings in the surgery’s computer system. I should like this to be carefully investigated and look forward to hearing with a response within the relevant time period. I realise that the situation may be exacerbated by GPs working part time and many part time practitioners being involved in the prescribing procedure as well as many receptionists being involved in it but if this is the trend then it seems to me the safeguards must be extended not made easier to override. The other ‘failsafe device’ is the dispensing pharmacist. When repeats are requested online there is a designated pharmacy. They receive emailed scripts. Their own systems should flag up cases of over or too frequent prescribing as well as other matters. ”
    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 NHS Brighton and Hove Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of prescribing-system warnings to prevent inappropriate override

    Wider context from the report

    “The method of prescribing medication such as Zopiclone (in this case), Codeine, Morphine, Benzodiazepines etc. to patients which suggests that they either are or are very likely to be becoming dependent upon such medications or are misusing them. Examples of both the above would be too frequent requests for repeat prescriptions and information concerning a history of overdoses. The Inquest discussed whether circumstances, including those outlined above should trigger an automatic/mandatory medication review conducted with the patient; consideration of a different prescribing period and very careful monitoring of the online requests for repeat prescriptions. Alternatively, there could be a ban on the requests for repeat prescriptions with the repeats simply being issued for an appropriate period of time “automatically”. In this case as you will see from ████████ report, over twice the appropriate amount of Zopiclone was issued over a period of 57 days. The patient in question had Zopiclone present at a fatal level in his blood at the time of his collapse from which he never recovered. I remain very worried about these prescribing issues and about the fact that apparently receptionists and clinicians can override the warnings in the surgery’s computer system. I should like this to be carefully investigated and look forward to hearing with a response within the relevant time period. I realise that the situation may be exacerbated by GPs working part time and many part time practitioners being involved in the prescribing procedure as well as many receptionists being involved in it but if this is the trend then it seems to me the safeguards must be extended not made easier to override. The other ‘failsafe device’ is the dispensing pharmacist. When repeats are requested online there is a designated pharmacy. They receive emailed scripts. Their own systems should flag up cases of over or too frequent prescribing as well as other matters. ”
    Open source report

  2. Brighton and Hove

    AI-generated summary

    Geoffrey John MOYSE · 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

    Geoffrey John MOYSE’s death was the subject of an inquest that concluded with a finding of Medical Misadventure. The report raised concerns about an eight-month delay in referral, poor communication between providers, and failures to transfer investigation results into the NHS system, leaving him unwell, undiagnosed and untreated for too long.

    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 NHS Brighton and Hove Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in referral to appropriate specialist services

    Wider context from the report

    “(1) Please see the attached letter dated the 19th December 2014 which explains the system which was put in place by the CCG. Please refer to Part 3 of the attached Record of Inquest to learn what happened in Mr Moyse’s case. It is clear to me from the evidence I heard at the Inquest that there was a huge delay in referring him (its right to say that some of that delay was due to Mr Moyse being unable to help speed the process up). Nonetheless, it took eight months from referral to seeing the appropriate Surgeon and I should imagine a referral direct to Digestive Diseases would have been substantially quicker than that. There was no understanding it seems by the people involved in the arrangements that it was probably possible to try and short circuit them. For example, why did the Consultant Gastroenterologist not contact the colorectal clinic himself or even copy his letter and his histology report sent to the GP on the 29th June 2015? Why did BICS, who were sent a copy of the histology report, not forward this to anyone else e.g. the colo-rectal clinic to see whether it would produce the urgent result which the GP was seeking to achieve? Could the GP have done a two week referral at the very beginning? Would that have come within Code 2 on the letter of the 19th December 2015? If he had, perhaps the whole system would have worked. One of the problems in existence appears to be that because the initiative involves private hospitals, some private hospitals will use their own histo-pathologists to analyse results of procedures such as colonoscopies instead of using the National Health laboratories. This means that the results do not automatically feed in to the local NHS system. Surely it would be possible to insist that all x-ray results, MRI scans, CT scans, histopathology reports etc. etc. which arise in this way as part of an NHS initiative involving the private sector must be transmitted back into the NHS system at the earliest possible opportunity. It just seems to me that this system broke down because these processes seem to work with any reference to a joined up approach and the person who suffers is the patient. In this case I was eventually satisfied that this did not adversely affect the outcome with Mr Moyse but certainly it meant that the whole process for him was hugely delayed and he was left unwell, undiagnosed and untreated for far, far too long. I would like to see a complete review of this process and I am sure that Mrs Moyse would be happy, suitably anonymised, if Mr Moyse’s case could be used to ensure that this does not happen again to another patient where this delay might have been fatal on its own. ”
    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 NHS Brighton and Hove Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to transmit private-sector diagnostic results into the local NHS system

    Wider context from the report

    “(1) Please see the attached letter dated the 19th December 2014 which explains the system which was put in place by the CCG. Please refer to Part 3 of the attached Record of Inquest to learn what happened in Mr Moyse’s case. It is clear to me from the evidence I heard at the Inquest that there was a huge delay in referring him (its right to say that some of that delay was due to Mr Moyse being unable to help speed the process up). Nonetheless, it took eight months from referral to seeing the appropriate Surgeon and I should imagine a referral direct to Digestive Diseases would have been substantially quicker than that. There was no understanding it seems by the people involved in the arrangements that it was probably possible to try and short circuit them. For example, why did the Consultant Gastroenterologist not contact the colorectal clinic himself or even copy his letter and his histology report sent to the GP on the 29th June 2015? Why did BICS, who were sent a copy of the histology report, not forward this to anyone else e.g. the colo-rectal clinic to see whether it would produce the urgent result which the GP was seeking to achieve? Could the GP have done a two week referral at the very beginning? Would that have come within Code 2 on the letter of the 19th December 2015? If he had, perhaps the whole system would have worked. One of the problems in existence appears to be that because the initiative involves private hospitals, some private hospitals will use their own histo-pathologists to analyse results of procedures such as colonoscopies instead of using the National Health laboratories. This means that the results do not automatically feed in to the local NHS system. Surely it would be possible to insist that all x-ray results, MRI scans, CT scans, histopathology reports etc. etc. which arise in this way as part of an NHS initiative involving the private sector must be transmitted back into the NHS system at the earliest possible opportunity. It just seems to me that this system broke down because these processes seem to work with any reference to a joined up approach and the person who suffers is the patient. In this case I was eventually satisfied that this did not adversely affect the outcome with Mr Moyse but certainly it meant that the whole process for him was hugely delayed and he was left unwell, undiagnosed and untreated for far, far too long. I would like to see a complete review of this process and I am sure that Mrs Moyse would be happy, suitably anonymised, if Mr Moyse’s case could be used to ensure that this does not happen again to another patient where this delay might have been fatal on its own. ”
    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 NHS Brighton and Hove Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise and use available expedited referral routes

    Wider context from the report

    “(1) Please see the attached letter dated the 19th December 2014 which explains the system which was put in place by the CCG. Please refer to Part 3 of the attached Record of Inquest to learn what happened in Mr Moyse’s case. It is clear to me from the evidence I heard at the Inquest that there was a huge delay in referring him (its right to say that some of that delay was due to Mr Moyse being unable to help speed the process up). Nonetheless, it took eight months from referral to seeing the appropriate Surgeon and I should imagine a referral direct to Digestive Diseases would have been substantially quicker than that. There was no understanding it seems by the people involved in the arrangements that it was probably possible to try and short circuit them. For example, why did the Consultant Gastroenterologist not contact the colorectal clinic himself or even copy his letter and his histology report sent to the GP on the 29th June 2015? Why did BICS, who were sent a copy of the histology report, not forward this to anyone else e.g. the colo-rectal clinic to see whether it would produce the urgent result which the GP was seeking to achieve? Could the GP have done a two week referral at the very beginning? Would that have come within Code 2 on the letter of the 19th December 2015? If he had, perhaps the whole system would have worked. One of the problems in existence appears to be that because the initiative involves private hospitals, some private hospitals will use their own histo-pathologists to analyse results of procedures such as colonoscopies instead of using the National Health laboratories. This means that the results do not automatically feed in to the local NHS system. Surely it would be possible to insist that all x-ray results, MRI scans, CT scans, histopathology reports etc. etc. which arise in this way as part of an NHS initiative involving the private sector must be transmitted back into the NHS system at the earliest possible opportunity. It just seems to me that this system broke down because these processes seem to work with any reference to a joined up approach and the person who suffers is the patient. In this case I was eventually satisfied that this did not adversely affect the outcome with Mr Moyse but certainly it meant that the whole process for him was hugely delayed and he was left unwell, undiagnosed and untreated for far, far too long. I would like to see a complete review of this process and I am sure that Mrs Moyse would be happy, suitably anonymised, if Mr Moyse’s case could be used to ensure that this does not happen again to another patient where this delay might have been fatal on its own. ”
    Open source report
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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