Recipient

Recipient name withheld

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First report 10 Jan 2014•Latest report 10 Jan 2014

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Staffordshire South

    AI-generated summary

    Pauline Meredith · 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

    Pauline Meredith, aged 42, was found dead in her flat on 30 August 2013. Her death was attributed to mixed drug toxicity, including a fatal level of morphine, excessive levels of tramadol and propranolol, and alcohol. Concerns included the amount and review of prescribed medication, the addition of morphine alongside existing medication and alcohol dependence, the response to family concerns, the absence of team meetings, and delays in involving community mental health services.

    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a formal medication review process for long-term medication prescribing

    Wider context from the report

    “(1) The amount of medication prescribed to the deceased over many years with no formal medication review 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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to listen to family concerns about changed patient behaviour

    Wider context from the report

    “(3) The family’s perceived reluctance by the GP to listen to the concerns expressed by them with regards to the changed behaviour of the patient following the addition of morphine. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of team meetings to discuss challenging patients

    Wider context from the report

    “(4) The lack of any team meetings with colleagues affording an opportunity to discuss challenging patients with colleagues. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to safely assess morphine prescribing alongside high-dose painkillers and alcohol dependence

    Wider context from the report

    “(2) The more recent addition of morphine to the prescription for a patient already on a high dose of pain killers and with alcohol dependence ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a timely proactive approach to involving community mental health services

    Wider context from the report

    “(5) The lack of a more timely proactive approach with regards to involving community mental health services. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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