Concerns raised 3 Lack of overarching guidance directing GPs to the appropriate cardiology pathway for complex cases View source Ambiguity in urgent referral terminology and third-party providers’ understanding of available cardiology pathways View source Failure to ensure consistent understanding of the process for expediting or replacing cardiology referrals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Costas CHRYSOSTOMOU · 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
Costas Chrysostomou died in hospital on 14 December 2024 after developing cardiac failure and acute renal failure linked to pacemaker-mediated cardiomyopathy, described as a rare but known complication. The report raised concerns about ambiguity in the use of “urgent” referrals, differing understandings of cardiology pathways between GPs and hospital consultants, and the need for clearer guidance for complex cases.
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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of overarching guidance directing GPs to the appropriate cardiology pathway for complex cases
Wider context from the report “2) Understanding of Pathways
a. I heard evidence from cardiology consultants and a GP. It was clear that understanding of the operation of the Pathways differs considerably. One example was that some GPs consider that by custom and practice, if following a routine cardiology referral new clinical information comes to light requiring a patient’s referral to expedited or made ‘urgent’, this can be done by emailing the hospital team concerned and adding the information. However, the view of the hospital consultants is that this is not the case and that if an expedited or urgent referral becomes necessary then the referral process requires re-starting as a new and entirely separate referral. In my opinion, this confusion has the potential to create significant risk.
b. I also heard evidence more generally that with more complex specialisms/cases GPs could be assisted with overarching guidance that helps direct them to the most appropriate Pathway. At present, I was told, that the system relies on the GP being confident as to which Pathway is appropriate, which is understandably not always the case.
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in urgent referral terminology and third-party providers’ understanding of available cardiology pathways
Wider context from the report “1) Use of the term ‘urgent’ and understanding by third-party providers of the specific Pathways available
Following implantation of the pacemaker, Mr Chrysostomou’s GP was charged with arranging a follow-up outpatient cardiology appointment and arranging for an echocardiogram (Echo). Both actions were undertaken by the GP.
A referral to the cardiology team at the Royal Free Hospital was made under what I was told was a ‘generic’ cardiology pathway as there was no expectation, at that time, for a more specific pathway to be used. The Echo was undertaken by a third-party (private) provider, contracted to provide services to the NHS. The Echo report was headed in large bold writing: ‘Suggest Urgent Cardiac Referral’. The bottom of the Echo report repeats that recommendation next to the heading ‘Onward Recommendations’.
The evidence I heard indicated that there are numerous potential cardiac/cardiology pathways available. The concern regarding the use of the term ‘urgent’ is that I heard evidence that this is open to interpretation; for example, there is in some Pathways an ‘Urgent 6 weeks’ type of referral and also an ‘Urgent (<2 weeks)’ type of referral. It is possible that the third-party provider(s) may not be aware of the differences and/or not sufficiently aware of the NHS ICB Pathways available, which is leading to confusion.
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure consistent understanding of the process for expediting or replacing cardiology referrals
Wider context from the report “2) Understanding of Pathways
a. I heard evidence from cardiology consultants and a GP. It was clear that understanding of the operation of the Pathways differs considerably. One example was that some GPs consider that by custom and practice, if following a routine cardiology referral new clinical information comes to light requiring a patient’s referral to expedited or made ‘urgent’, this can be done by emailing the hospital team concerned and adding the information. However, the view of the hospital consultants is that this is not the case and that if an expedited or urgent referral becomes necessary then the referral process requires re-starting as a new and entirely separate referral. In my opinion, this confusion has the potential to create significant risk.
b. I also heard evidence more generally that with more complex specialisms/cases GPs could be assisted with overarching guidance that helps direct them to the most appropriate Pathway. At present, I was told, that the system relies on the GP being confident as to which Pathway is appropriate, which is understandably not always the case.
” Open source report
Concerns raised 21 Provision of incorrect advice that an adrenaline auto injector switch is only a brand substitution View source Failure to reconsider adrenaline auto injector dose after switching device View source Inadequate and incorrect national training content for 111 call handlers on adrenaline auto injectors View source Failure to identify patients at particularly high risk from allergies and asthma View source Lack of named accountability for allergy services and provision View source Failure to assess patients’ access to and understanding of adrenaline auto injector advice View source Failure of the Adastra system to update location information across screens in real time View source Failure to establish whether specialist allergy care was being provided View source Inconsistency in anaphylaxis ambulance categorisation between 999 and 111 services View source Failure to explain the need for sequential administration of two adrenaline auto injectors in acute anaphylaxis View source Failure of 111 call audits to identify all significant call-handling failings View source Rare provision of practical placebo-device adrenaline auto injector training View source Failure to provide healthcare-professional training after an adrenaline auto injector switch View source Failure to communicate device-specific training requirements for adrenaline auto injectors View source Failure of NHS Digital to retain and act on previously identified call-handling safety issues View source Failure of AAI leaflets to specify the need for device-specific healthcare-professional training View source Failure of the 999 service to safety-net inappropriate 111 categorisation View source Single-sale availability of Emerade adrenaline auto injectors View source Failure to record and emphasise the need to carry two adrenaline auto injector pens View source Failure to advise prescribers to reconsider adrenaline auto injector dose after a device switch View source Failure to display the advice to carry two adrenaline auto injectors on the outside of the box View source See 18 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Shanté Andrée Marie TURAY-THOMAS · 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
Shanté Andrée Marie Turay-Thomas ate hazelnuts on 18 September 2018 and died soon afterwards from acute anaphylaxis. The report identifies concerns about inadequate allergy care, advice and training concerning adrenaline auto-injectors, prescribing and clinical communication, and errors in the NHS 111 response and ambulance categorisation.
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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Provision of incorrect advice that an adrenaline auto injector switch is only a brand substitution
Wider context from the report “7. The GPs relied upon the advice given by Enfield Clinical Commissioning Group (CCG) that the scriptswitch was simply the replacement of one branded product with another branded product of the same drug/device . This gave false reassurance. The CCG joint formulary committee introduced a new drug for GPs, but then gave the wrong advice to accompany this .
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to reconsider adrenaline auto injector dose after switching device
Wider context from the report “5. When Shanté’s AAI was changed from an EpiPen to an Emerade, her GPs failed to reconsider the prescription and to increase her dose from 300mgs to 500mcgs .
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate and incorrect national training content for 111 call handlers on adrenaline auto injectors
Wider context from the report “17. In terms of national training for 111 call handlers, the NHS Digital distance learning pack contains advice that is in part inadequate and in part wrong . It does not give the crucial information that one dose of adrenaline, by whichever device it is administered, is very unlikely to be sufficient in the case of acute anaphylaxis . It contains a photograph to illustrate the use of an AAI, but in the photograph the device is held incorrectly .
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to identify patients at particularly high risk from allergies and asthma
Wider context from the report “1. At the time of her death, Shanté was not receiving specialist care for her allergies. However, her general practitioners (GPs) failed to appreciate this. They assumed that she was being treated for her allergies at the transitional asthma clinic to which she had been referred following her paediatric discharge. This was an incorrect assumption.
The GPs had not identified Shanté (who had a high BMI and was severely allergic) as being at particularly high risk from her allergies and asthma, and had no awareness that they were the sole providers of Shanté’s allergy care.
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of named accountability for allergy services and provision
Wider context from the report “20. The issues within this prevention of future deaths report are predominantly national issues, but I heard at inquest that there is no person with named accountability for allergy services and allergy provision at NHS England or the Department of Health as a whole .
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to assess patients’ access to and understanding of adrenaline auto injector advice
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her.
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other, to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen . They did not explore with her where she kept her pens . They did not test her understanding of medical advice .
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the Adastra system to update location information across screens in real time
Wider context from the report “14. When Shanté became ill following the ingestion of nuts, her mother rang NHS 111 and got through to the London Central & West (LCW) service. However, the call handler incorrectly recorded Shanté’s location: he failed to untick a box and so her grandmother’s address was recorded as her location, rather than her mother’s address where she was staying at the time.
In an example of good practice, this error was recognised by the clinician who later took over the call. However, what nobody at LCW realised was that the Adastra computer system would not then update in real time for any screens save that of the particular clinician inputting the information .
The staff at LCW have since been made aware of this and have been trained to walk over and look at the primary screen to check the address, but it is not clear to me that there is now a national understanding of that element of the system.
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to establish whether specialist allergy care was being provided
Wider context from the report “1. At the time of her death, Shanté was not receiving specialist care for her allergies. However, her general practitioners (GPs) failed to appreciate this . They assumed that she was being treated for her allergies at the transitional asthma clinic to which she had been referred following her paediatric discharge. This was an incorrect assumption.
The GPs had not identified Shanté (who had a high BMI and was severely allergic) as being at particularly high risk from her allergies and asthma, and had no awareness that they were the sole providers of Shanté’s allergy care.
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inconsistency in anaphylaxis ambulance categorisation between 999 and 111 services
Wider context from the report “16. The individuals making these errors were working within the context of NHS Digital’s categorisation of anaphylaxis as needing a category 2 ambulance rather than a category 1 ambulance, on the Adastra computer system that supports the LCW 111 service.
This was the wrong categorisation and not the categorisation that the call would have received if 999 had been called and the London Ambulance Service contacted in the first instance. Acute anaphylaxis is immediately life threatening and must be treated as a category 1.
I heard at inquest that NHS Digital has since changed its categorisation. However, I also heard that for those areas (I think approximately half the country, though this is not completely clear to me), where the 999 service and the 111 service are supported by different computer systems rather than the same system being common to both services, there could remain inconsistencies of categorisation between 999 and 111 .
Even where there are inconsistencies in categorisation, the 999 service will not re-categorise following a 111 clinician’s categorisation, unless a 999 clinician has spoken to the patient, so inappropriate 111 categorisation will not be safety netted by the 999 service. This must be recognised and factored in.
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to explain the need for sequential administration of two adrenaline auto injectors in acute anaphylaxis
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her.
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other , to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen. They did not explore with her where she kept her pens. They did not test her understanding of medical advice.
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of 111 call audits to identify all significant call-handling failings
Wider context from the report “15. During the course of the 111 call, a number of errors were made. These were the errors of LCW individuals. When LCW audited the call in the first instance, the audit identified the problem with the address, but failed to recognise how badly the call had gone in other ways . Without effective audit and recognition of failings, it is difficult to see how there can be effective improvement .
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Rare provision of practical placebo-device adrenaline auto injector training
Wider context from the report “13. I heard that the gold standard of training for use of any AAI is to give the patient the relevant pen (whichever that patient is prescribed) containing a placebo rather than adrenaline and, following appropriate instruction, ask the patient actually to administer a dose.
I heard at inquest that the incidence of this standard of training (in any setting) is rare . That may be for good reasons, but it seems that revisiting best practice training at a national level would be helpful.
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide healthcare-professional training after an adrenaline auto injector switch
Wider context from the report “6. Following the scriptswitch, the GPs failed to ask Shanté to come in to the surgery for training in use of the Emerade . This would also have presented an ideal opportunity to explore Shanté’s understanding of the use of her pens and to ensure that she understood she needed to carry two at all times.
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate device-specific training requirements for adrenaline auto injectors
Wider context from the report “9. The CCG failed to inform prescribers that the Emerade pen requires different training to the EpiPen because different AAIs do not operate in the same way. In fact, the CCG gave the opposite advice .
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS Digital to retain and act on previously identified call-handling safety issues
Wider context from the report “19. One of the errors made by the first 111 call handler was a failure to ask to speak direct to the patient. This was the error of an individual.
However, this is not the first time that the issue has been brought to the attention of NHS Digital. At inquest, I asked the witness who appeared on behalf of NHS Digital, and indeed had been chosen by NHS Digital as the person best able to assist the court, if this had been an issue in the past. He said no. However, on 18 December 2018, Peter Harrowing, HM Assistant Coroner for Avon, sent a prevention of future deaths report to NHS Digital following the inquest touching the death of David Longden.
It was only when I asked the witness appearing on behalf of NHS Digital specifically about Coroner Harrowing’s report in respect of Mr Longden, pointing out that Coroner Harrowing had raised the need for NHS Digital to place greater emphasis on the call handler speaking to the patient, that the witness remembered that he had indeed seen that report.
I choose to characterise this as a memory lapse rather than as an intention wilfully to mislead the court. (A witness who lies whilst giving evidence on oath at inquest may be found in contempt of court and may even be prosecuted for the crime of perjury.) Nevertheless, if NHS Digital does not have a grasp of this sort of detail, specifically brought to its attention by a coroner in a prevention of future deaths report, it is difficult to see how there can be effective improvement .
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of AAI leaflets to specify the need for device-specific healthcare-professional training
Wider context from the report “12. The Emerade AAI (and I assume the EpiPen and JEXT) leaflet does not specifically advise that training from a healthcare professional is needed in how to use this particular AAI as opposed to any other .
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the 999 service to safety-net inappropriate 111 categorisation
Wider context from the report “16. The individuals making these errors were working within the context of NHS Digital’s categorisation of anaphylaxis as needing a category 2 ambulance rather than a category 1 ambulance, on the Adastra computer system that supports the LCW 111 service.
This was the wrong categorisation and not the categorisation that the call would have received if 999 had been called and the London Ambulance Service contacted in the first instance. Acute anaphylaxis is immediately life threatening and must be treated as a category 1.
I heard at inquest that NHS Digital has since changed its categorisation. However, I also heard that for those areas (I think approximately half the country, though this is not completely clear to me), where the 999 service and the 111 service are supported by different computer systems rather than the same system being common to both services, there could remain inconsistencies of categorisation between 999 and 111.
Even where there are inconsistencies in categorisation, the 999 service will not re-categorise following a 111 clinician’s categorisation, unless a 999 clinician has spoken to the patient , so inappropriate 111 categorisation will not be safety netted by the 999 service . This must be recognised and factored in.
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Single-sale availability of Emerade adrenaline auto injectors
Wider context from the report “4. The Emerade AAI is sold singly . It could be sold in boxes of two as the norm and only singly in the alternative.
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to record and emphasise the need to carry two adrenaline auto injector pens
Wider context from the report “2. Shanté’s GPs knew that she should carry two adrenaline auto injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her .
They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other, to keep the patient alive until the arrival of an emergency ambulance.
The GPs did not explore with Shanté the reason for her erratic requests for a pen. They did not explore with her where she kept her pens. They did not test her understanding of medical advice.
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to advise prescribers to reconsider adrenaline auto injector dose after a device switch
Wider context from the report “8. The CCG failed to draw prescribers’ attention to the need, following scriptswitch from EpiPen to Emerade, to reconsider the dose and to prescribe the higher dose of 500mcgs for patients at higher risk (which would have included Shanté).
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to display the advice to carry two adrenaline auto injectors on the outside of the box
Wider context from the report “3. The Emerade AAI accompanying leaflet does include the advice that two pens should be carried at all times, but the advice is not re-iterated on the outside of the box . Consideration will need to be given to whether this is the appropriate advice in all cases, but it seems worthwhile to review the issue as a whole.
” Open source report
Concerns raised 2 Lack of auditability of long and complex 999 and 111 calls View source Failure to prevent call takers from downgrading calls to lower-acuity pathways View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ms Samia Yasmin Shara · 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
Ms Samia Yasmin Shara, aged 15, died from acute heart failure caused by an aneurysm of the aortic sinus and a ruptured cusp of the aortic valve, following an undiagnosed congenital heart problem. Her brother made calls to 999 and 111, but the seriousness of her condition was not recognised until the final 999 call, delaying emergency ambulance services. Concerns included the audit of complex 999 and 111 calls and preventing call takers from downgrading calls to a lower-acuity pathway.
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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of auditability of long and complex 999 and 111 calls
Wider context from the report “(1) That long and complex calls made to 999 and 111 should be available for audit by the CCG to identify learning opportunities and thus improve outcomes via a quality assurance process.
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent call takers from downgrading calls to lower-acuity pathways
Wider context from the report “(2) That call takers should not be able to downgrade a call by moving to a pathway of lower acuity .
” Open source report
Concerns raised 2 Failure to communicate medication changes between the GP practice and responsible clinician View source Failure to ensure medication directions and labels correspond to the prescribed use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Tanya Rosemary Marion Oladejo · 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
Tanya Rosemary Marion Oladejo was found collapsed and unresponsive on her bed after a friend had not heard from her for approximately one week; police confirmed there were no suspicious circumstances. The inquest concluded misadventure, with the medical cause of death recorded as amitriptyline intoxication. The principal concern was inadequate communication between the GP practice and the responsible clinician about medication, including unilateral changes to amitriptyline prescribing that were not communicated to the responsible clinician.
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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate medication changes between the GP practice and responsible clinician
Wider context from the report “(1) The responsible clinician had made adjustments to the prescribed medication regime including allowing the GP to vary the amount of sertraline according to the patient’s presentation.
(2) The GP, in fact, also on occasion titrated the amount of amitriptyline prescribed according to the patient’s presentation.
(3) The responsible clinician was not made aware of the unilateral titration of amitriptyline so, accordingly, was unaware that a drug she had (in discussion with the patient) prescribed to be used as a sleeping draft was, in fact, being prescribed clearly labelled to be taken in the mornings.
(4) In this case, there was a worrying lack of adequate communication between the GP practice and the responsible clinician about medication prescribed to assist in controlling Tanya’s condition
” 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 West and North London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medication directions and labels correspond to the prescribed use
Wider context from the report “(1) The responsible clinician had made adjustments to the prescribed medication regime including allowing the GP to vary the amount of sertraline according to the patient’s presentation.
(2) The GP, in fact, also on occasion titrated the amount of amitriptyline prescribed according to the patient’s presentation.
(3) The responsible clinician was not made aware of the unilateral titration of amitriptyline so, accordingly, was unaware that a drug she had (in discussion with the patient) prescribed to be used as a sleeping draft was, in fact, being prescribed clearly labelled to be taken in the mornings.
(4) In this case, there was a worrying lack of adequate communication between the GP practice and the responsible clinician about medication prescribed to assist in controlling Tanya’s condition
” Open source report
Pin
Request correction
Addressed to NHS North Central London Integrated Care Board, now represented here by NHS West and North London Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations