Recipient

North Laine Medical Centre

First report 15 Jun 2018•Latest report 15 Jun 2018

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: 2
Stated actions: 16

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

16stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from North Laine Medical Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

15 Jun2018
Brighton and Hove
Concerns raised2
1. Failure to apply adequate safeguards when prescribing potentially dependence-forming or misused medication
2. Failure of prescribing-system warnings to prevent inappropriate override
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 10
1. Action
  Code all overdoses and suicide attempts in the practice system.
  Stated completed
2. Action
  Develop a computer-generated warning identifying patients with overdoses or suicide attempts when high-risk medicines are requested.
  Stated in progress
3. Action
  Add patients who overdose to the weekly prescription list.
  Stated planned
1. Action
  Review patients receiving controlled drugs and agree medication-reduction or cessation plans with them.
  Stated in progress
2. Action
  Revise the practice prescribing policy using CCG pharmaceutical advice and discuss the updated policy in a whole-practice meeting.
  Stated completed
3. Action
  Change computer-system thresholds so early-order warnings appear one day before due dates and online ordering closes three days before due dates.
  Stated completed
4. Action
  Raise receptionist and GP awareness of patients ordering prescriptions too early, including when requested amounts appear small.
  Stated completed
5. Action
  Remove online prescription requests for controlled drugs and drugs of potential abuse or dependence, following patient assessment.
  Stated in progress
6. Action
  Copy all GPs into reports of overdoses and other suicide attempts.
  Stated completed
7. Action
  Audit Zopiclone prescribing to verify repeat-template intervals, doses and limits, and reduce some prescription amounts.
  Stated completed
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 North Laine Medical Centre; 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 North Laine Medical Centre; 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
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
Code all overdoses and suicide attempts in the practice system.

Verbatim wording from the response
“Action plan following meeting held on 22nd May which have been implemented by the practice.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 3 · response
Published 8 July 2018
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
Develop a computer-generated warning identifying patients with overdoses or suicide attempts when high-risk medicines are requested.

Verbatim wording from the response
“10. A further meeting is planned with the practice IT coordinator to highlight automatically patients who have taken an overdose when certain high-risk drugs are requested. We hope to have this in place shortly.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Add patients who overdose to the weekly prescription list.

Verbatim wording from the response
“5. Patients who overdose will be added to the weekly script list.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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 patients receiving controlled drugs and agree medication-reduction or cessation plans with them.

Verbatim wording from the response
“9. A whole practice meeting took place on 24th July to discuss the updated practice prescribing policy. Ongoing review of patients on controlled drugs ████████ ████████ will occur and a plan to reduce and/or stop agreed with the patient. This will complement what the practice already has put in place over the past 2 years in terms of reduction programmes for patients.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Revise the practice prescribing policy using CCG pharmaceutical advice and discuss the updated policy in a whole-practice meeting.

Verbatim wording from the response
“6. There has been an extensive revision of the practice prescribing policy incorporating suggestions from the CCG pharmaceutical adviser and we are having a practice meeting on 24th July to discuss further. We look forward to working with her again over the next year to improve further our systems.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Change computer-system thresholds so early-order warnings appear one day before due dates and online ordering closes three days before due dates.

Verbatim wording from the response
“4. An investigation into online ordering and script generation by the computer system was conducted in conjunction with the practice IT co-ordinator. As a result, the timings were changed within the system so that warnings about scripts being ordered too early were changed from 7 to 1 day and ordering online from 10 to 3 days.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Raise receptionist and GP awareness of patients ordering prescriptions too early, including when requested amounts appear small.

Verbatim wording from the response
“7. There has been a raised awareness of the potential of any patient to over-order medication, whether by accident or design.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Remove online prescription requests for controlled drugs and drugs of potential abuse or dependence, following patient assessment.

Verbatim wording from the response
“3. Access to online requests for controlled drugs has been removed for all patients. Following discussion with the patient and their doctor, this may be restored if the patient is considered “low-risk”.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Copy all GPs into reports of overdoses and other suicide attempts.

Verbatim wording from the response
“Action plan following meeting held on 22nd May which have been implemented by the practice.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 3 · response
Published 8 July 2018
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
Audit Zopiclone prescribing to verify repeat-template intervals, doses and limits, and reduce some prescription amounts.

Verbatim wording from the response
“2. An audit of all patients on Zopiclone was carried out to ensure that limits and doses were correctly entered on the system. There was no evidence that any other patients had over-ordered or done so too early.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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 raised2

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

Failure of prescribing-system warnings to prevent inappropriate override

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.10

Actions described in response 10