28 Jun 2024 Debra BATES · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 3 Failure to limit prescription quantities to an appropriate 3- or 4-day supply View source Failure to investigate safe implementation of short-cycle prescribing and available computer safety measures View source Failure to prevent or minimise incorrect prescription-duration selection View source
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. 5
Action
Implement and circulate a standard operating procedure for safely managing three- and four-day prescriptions, including clinician-only issuing, scheduling, alerts, coding and regular review.
View source
Action
Review the three- and four-day prescribing SOP in July 2025.
View source
Action
Consult local practices and the ICB prescribing team about managing frequent prescriptions and incorporate relevant learning into the practice SOP.
View source
Action
Seek information from the Community Mental Health Team about frequent-prescription processes and ongoing review requirements.
View source
Action
Add a READ code and home-screen safety alert to records of patients receiving three- or four-day prescriptions.
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AI-generated summary
Debra BATES · 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
Debra Bates was found dead at home on 15 June 2023. Post-mortem toxicology found prescribed medication at above therapeutic levels, and the evidence indicated that a mixture of medication had an enhanced sedative and respiratory depressant effect. A prior recommendation to change her prescriptions from weekly supplies to a three-day and four-day cycle was not implemented; concerns included the continuation of weekly prescribing and insufficient investigation of how to implement the proposed approach safely.
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× 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 Park Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to limit prescription quantities to an appropriate 3- or 4-day supply
Wider context from the report “A recommendation had been made by ████████, Consultant Psychiatrist for regular prescriptions to be supplied (blisters) on a 3 days followed by a 4 days cycle. This would limit the amount of prescription medication available to her at anyone time. Debra Bates had a chaotic prescription pill use which appears to be fuelling her turbulence
The dispensing pharmacist said that non blister pack 3 and 4 day prescription can be facilitated. These could be post dated to be collected on Tuesdays and Fridays for example.
A task was sent to the practice pharmacist to discuss the case. The response was that 3 and 4 day prescriptions could cause confusion as double items would need to be added to the repeat prescription for each duration. This would result in more frequent deliveries and could cause issues.
The regular prescriptions continued to be issued weekly (7 days)
In evidence ████████ said there would be a risk of over prescribing because by mistake a request for a 4 day prescription would be selected on the computer screen rather than a 3 day
No further investigation or inquiries were made as to how other practices implemented this prescribing approach in a case where there are multiple medications (including controlled drugs) or whether / what safety measures are available on the computer system, to prevent / minimise the risk of the wrong prescription being requested
” 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 Park Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate safe implementation of short-cycle prescribing and available computer safety measures
Wider context from the report “A recommendation had been made by ████████, Consultant Psychiatrist for regular prescriptions to be supplied (blisters) on a 3 days followed by a 4 days cycle. This would limit the amount of prescription medication available to her at anyone time. Debra Bates had a chaotic prescription pill use which appears to be fuelling her turbulence
The dispensing pharmacist said that non blister pack 3 and 4 day prescription can be facilitated. These could be post dated to be collected on Tuesdays and Fridays for example.
A task was sent to the practice pharmacist to discuss the case. The response was that 3 and 4 day prescriptions could cause confusion as double items would need to be added to the repeat prescription for each duration. This would result in more frequent deliveries and could cause issues.
The regular prescriptions continued to be issued weekly (7 days)
In evidence ████████ said there would be a risk of over prescribing because by mistake a request for a 4 day prescription would be selected on the computer screen rather than a 3 day
No further investigation or inquiries were made as to how other practices implemented this prescribing approach in a case where there are multiple medications (including controlled drugs) or whether / what safety measures are available on the computer system , to prevent / minimise the risk of the wrong prescription being requested
” 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 Park Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent or minimise incorrect prescription-duration selection
Wider context from the report “A recommendation had been made by ████████, Consultant Psychiatrist for regular prescriptions to be supplied (blisters) on a 3 days followed by a 4 days cycle. This would limit the amount of prescription medication available to her at anyone time. Debra Bates had a chaotic prescription pill use which appears to be fuelling her turbulence
The dispensing pharmacist said that non blister pack 3 and 4 day prescription can be facilitated. These could be post dated to be collected on Tuesdays and Fridays for example.
A task was sent to the practice pharmacist to discuss the case. The response was that 3 and 4 day prescriptions could cause confusion as double items would need to be added to the repeat prescription for each duration. This would result in more frequent deliveries and could cause issues.
The regular prescriptions continued to be issued weekly (7 days)
In evidence ████████ said there would be a risk of over prescribing because by mistake a request for a 4 day prescription would be selected on the computer screen rather than a 3 day
No further investigation or inquiries were made as to how other practices implemented this prescribing approach in a case where there are multiple medications (including controlled drugs) or whether / what safety measures are available on the computer system, to prevent / minimise the risk of the wrong prescription being requested
” 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 Implement and circulate a standard operating procedure for safely managing three- and four-day prescriptions, including clinician-only issuing, scheduling, alerts, coding and regular review.
Verbatim wording from the response “A draft SOP was prepared and discussed with the PCN Pharmacist on 18 July 2024. Amendments were made to remove any direct role for the PCN Pharmacists as they did not feel there was sufficient capacity within their team to respond in a timely manner to urgent requests. The SOP was reviewed and agreed at the Partners meeting the same day. The Lead GP for Mental” Source location Response from Park Surgery Heanor
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 Review the three- and four-day prescribing SOP in July 2025.
Verbatim wording from the response “3. The SOP will be reviewed in July 2025.” Source location Response from Park Surgery Heanor
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 Consult local practices and the ICB prescribing team about managing frequent prescriptions and incorporate relevant learning into the practice SOP.
Verbatim wording from the response “iii. Contact prescribing lead GPs in other local PCN Practices to enquire about experience with (and policies for) managing twice weekly prescriptions.” Source location Response from Park Surgery Heanor
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 Seek information from the Community Mental Health Team about frequent-prescription processes and ongoing review requirements.
Verbatim wording from the response “v. Contact the Community Mental Health Team (CMHT) to see if they have any policies regarding their processes for requesting 3 and 4-day prescriptions from GPs and also ensuring ongoing review of such patients, including whether there is a continuing need for twice-weekly prescriptions.” Source location Response from Park Surgery Heanor
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 Add a READ code and home-screen safety alert to records of patients receiving three- or four-day prescriptions.
Verbatim wording from the response “We agreed that administrative staff, who normally issue repeat prescriptions, should not be involved in issuing medications for patients on 3 and 4-day prescriptions. This is to reduce the risk of errors when issuing twice-dated prescriptions for medications where each item appears twice on the repeat medication list. We noted that we would need to include a reminder in the home screen for any patients on twice-weekly prescriptions, to alert staff that the patient is on twice-weekly prescriptions, and that we would create a READ code ‘Risk Reduction technique’ for audit purposes.” Source location Response from Park Surgery Heanor
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations