Petroc Group Practice

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First report 12 Jun 2024•Latest report 12 Jun 2024

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: 1
Published responses: 100%
Concerns addressed: 4
Stated actions: 5

Concerns and recipient responses

Statements from Petroc Group Practice linked to the concerns in each report. Select any concern, action or position to view the source wording.

12 Jun2024
Cornwall and Isles of Scilly
Concerns raised5
1. Lack of GP practice policy for co-prescription of opioids and benzodiazepines
2. Unavailability of practice warning flags at the three-month stage of morphine prescribing
3. Lack of GP practice policy for long-term opioid prescribing
1. Failure to agree an opioid treatment strategy and end-of-treatment plan before starting opioids
2. Lack of practice policy requiring agreement of an opioid treatment strategy and end-of-treatment plan
Actions described in response 3
1. Action
  Raise opioid prescribing as a significant event for practice-wide consideration.
2. Action
  Develop a comprehensive practice policy for opioid prescribing.
3. Action
  Discuss the opioid prescribing policy and its application at the scheduled practice-wide meeting, then circulate the minutes and policy to staff.
AI-generated summary

Louise Helen Jones · 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

Louise Helen Jones was found deceased at home on 1 October 2023. The inquest recorded respiratory depression and opiate drug use, following an unintentional overdose involving morphine and bromazalam alongside other central nervous system depressant drugs. Concerns included the absence of an agreed opioid treatment and end-of-treatment plan, practice policies for long-term opioid prescribing and opioid–benzodiazepine co-prescribing, and warning flags after three months of morphine prescription.

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 Petroc Group Practice; that does not assign responsibility.
PFD Monitor interpretation
Lack of GP practice policy for co-prescription of opioids and benzodiazepines
Wider context from the report
“(4) There was no policy in place at the GP practice regarding co-prescription of opioids and benzodiazepines, to reflect the MHRA/CHM advice referred to in NICE guidance regarding the increased risk of respiratory depression and death. ”
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 Petroc Group Practice; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of practice warning flags at the three-month stage of morphine prescribing
Wider context from the report
“(3) There were no warning flags in place at the practice at the 3-month stage of morphine prescription, to reflect the MHRA/CHM advice referred to in NICE guidance, regarding the increased risk of addiction beyond this period. ”
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 Petroc Group Practice; that does not assign responsibility.
PFD Monitor interpretation
Lack of GP practice policy for long-term opioid prescribing
Wider context from the report
“(2) There was no policy in place at the GP practice regarding long term (longer than 3 months) prescription of opioids. ”
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 Petroc Group Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to agree an opioid treatment strategy and end-of-treatment plan before starting opioids
Wider context from the report
“(1) There was no agreement with Louise before starting opioids, regarding a treatment strategy and plan for end of treatment as recommended by NICE. There was no practice policy requiring such an agreement. ”
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 Petroc Group Practice; that does not assign responsibility.
PFD Monitor interpretation
Lack of practice policy requiring agreement of an opioid treatment strategy and end-of-treatment plan
Wider context from the report
“(1) There was no agreement with Louise before starting opioids, regarding a treatment strategy and plan for end of treatment as recommended by NICE. There was no practice policy requiring such an agreement. ”
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
Raise opioid prescribing as a significant event for practice-wide consideration.

Verbatim wording from the response
“2. Significant Event Discussion: We have raised this as a significant event and will discuss it at our next practice-wide meeting, scheduled for the 19th of September. During this meeting, we will cover the new policy and how it pertains to our approach to new and ongoing prescriptions for opioids. Minutes and copies of the policy will be circulated afterwards and made available to all staff.”

Source location
Response from Petroc Group
Page 1 · response
Published 25 June 2024
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 comprehensive practice policy for opioid prescribing.

Verbatim wording from the response
“In response to the points raised in the PFD report, we have developed a comprehensive practice policy for opioid prescribing. We believe this policy addresses points 1 to 4 in the report.”

Source location
Response from Petroc Group
Page 1 · response
Published 25 June 2024
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
Discuss the opioid prescribing policy and its application at the scheduled practice-wide meeting, then circulate the minutes and policy to staff.

Verbatim wording from the response
“2. Significant Event Discussion: We have raised this as a significant event and will discuss it at our next practice-wide meeting, scheduled for the 19th of September. During this meeting, we will cover the new policy and how it pertains to our approach to new and ongoing prescriptions for opioids. Minutes and copies of the policy will be circulated afterwards and made available to all staff.”

Source location
Response from Petroc Group
Page 1 · response
Published 25 June 2024
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 raised5

Lack of GP practice policy for co-prescription of opioids and benzodiazepines

Unavailability of practice warning flags at the three-month stage of morphine prescribing

Lack of GP practice policy for long-term opioid prescribing

Failure to agree an opioid treatment strategy and end-of-treatment plan before starting opioids

Lack of practice policy requiring agreement of an opioid treatment strategy and end-of-treatment plan

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.3

Actions described in response 3