Recipient

Riverview Surgery

First report 2 Feb 2026•Latest report 2 Feb 2026

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: 6
Stated actions: 12

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

12stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

2 Feb2026
Sunderland
Concerns raised6
1. Lack of advice about medication risks when considering having a child
2. Candesartan remaining available on repeat prescription during pregnancy
3. Failure to provide specific advice to stop Candesartan and identify its pregnancy risk
1. Failure to provide additional medication safety advice during antenatal care
2. Failure to conduct a detailed review of repeat prescription requests
3. Lack of system warnings identifying pregnancy during repeat prescribing
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Add pregnancy-stop warnings to electronic prescribing instructions so they appear on pharmacy-printed medication labels.
  Stated planned
2. Action
  Review all women of childbearing age taking ARB medicines and add prescription alerts advising immediate cessation and GP consultation if pregnancy occurs.
  Stated completed
3. Action
  Use reception tasks to trigger pregnancy coding, midwife referral checks and medication reviews, with duty-GP cover when unavailable.
  Stated completed
1. Action
  Increase reviews of women of childbearing age prescribed ARB medicines from six-monthly to three-monthly.
  Stated completed
2. Action
  Warn women taking Candesartan or other ARB medicines about pregnancy risks and the need to stop immediately if pregnancy occurs.
  Stated completed
3. Action
  Implement and apply an SOP covering pregnancy-related safety checks for new medicines, including stopping or replacing medicines unsafe in pregnancy.
  Stated completed
Respondent positions 1
1. Position
  Manually reviewing every repeat medication request and creating linked pregnancy alerts is impractical due to workload and lack of technical IT skills.
  Unable to act
AI-generated summary

Avery Jake Hall · 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

Avery Jake Hall died at Sunderland Royal Hospital on 13 November 2024, aged four days, after developing global hypoxia and diffuse alveolar damage following his birth. The report was concerned that his mother continued taking Candesartan during pregnancy because she was not given clear and definitive advice to stop it, and that the medication remained available on repeat prescription without warnings identifying her pregnancy.

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 Riverview Surgery; that does not assign responsibility.
PFD Monitor interpretation
Lack of advice about medication risks when considering having a child
Wider context from the report
“Avery’s mother suffered from migraines which were increasing in severity, so she sought advice from her GP when aged 21 years old. She was prescribed Candesartan 4mg by her GP shortly before her 22nd birthday. This was to be taken daily and was placed on a repeat prescription of 28 tablets. The dose was increased to 8mg after 3 months and following a referral, the treatment was endorsed by a Consultant Neurologist at a consultation 4 months after the initial prescription. The evidence revealed that no advice was provided as to the risks of this medication should she be considering having a child. ”
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 Riverview Surgery; that does not assign responsibility.
PFD Monitor interpretation
Candesartan remaining available on repeat prescription during pregnancy
Wider context from the report
“Avery’s mother continued to suffer from migraines during her pregnancy and was unaware of the risk posed by taking Candesartan in pregnancy due to a lack of clear and definitive advice about the risk. I am concerned that she was able to resume taking Candesartan approximately 14 days after her initial GP consultation as the medication remained on a repeat prescription which she was able to continue to request during her pregnancy, and each request was approved without a detailed review. The last repeat prescription being approved only 12 days prior to Avery’s birth. ”
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 Riverview Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide specific advice to stop Candesartan and identify its pregnancy risk
Wider context from the report
“Following a positive pregnancy test in April 2024, Avery’s mother sought advice from her GP about which of her prescribed medications were safe to use during pregnancy. During the telephone consultation with her GP on 11th April 2024 she was given specific advice to avoid using 3 of 6 prescriptions. I am concerned that the evidence highlighted that Avery’s mother was given only generic advice that it was best to avoid all medication during pregnancy but was not given specific advice to stop using Candesartan, and the risk of continuing to take this medication in pregnancy was not identified during this consultation. ”
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 Riverview Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide additional medication safety advice during antenatal care
Wider context from the report
“Although Avery’s mother had a number of attendances with clinicians throughout her antenatal care, the evidence revealed that she was given no additional advice regarding the safety of her medication and, whilst she was advised to seek advice from her GP as the prescriber, she did not feel it was necessary to do so having already had such a consultation in April 2024. ”
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 Riverview Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct a detailed review of repeat prescription requests
Wider context from the report
“Avery’s mother continued to suffer from migraines during her pregnancy and was unaware of the risk posed by taking Candesartan in pregnancy due to a lack of clear and definitive advice about the risk. I am concerned that she was able to resume taking Candesartan approximately 14 days after her initial GP consultation as the medication remained on a repeat prescription which she was able to continue to request during her pregnancy, and each request was approved without a detailed review. The last repeat prescription being approved only 12 days prior to Avery’s birth. ”
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 Riverview Surgery; that does not assign responsibility.
PFD Monitor interpretation
Lack of system warnings identifying pregnancy during repeat prescribing
Wider context from the report
“I am concerned that despite advice from the GP that it was best to stop all medication during pregnancy, Candesartan remained as a repeat prescription and, in addition to that, there were no warnings placed on the system which would have alerted the clinician approving the request for the repeat prescription that the patient was pregnant thus necessitating a review. ”
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
Add pregnancy-stop warnings to electronic prescribing instructions so they appear on pharmacy-printed medication labels.

Verbatim wording from the response
“3. As set out in the SEA, a review of all female patients of child bearing age who are prescribed ARB medication was to be undertaken every 6 months and an alert added to their prescription to stop taking this medication if they become pregnant and to speak to their GP. The frequency of this review has now been increased to 3-monthly in light of the risks of this medication in later pregnancy. In addition, as most prescriptions are now electronic rather than paper copies, the alert will be added to the prescribing instructions section so that it is clearly shown on the label printed for the patient’s medication by the pharmacy when they collect their medication.”

Source location
Response from Riverview Surgery
Page 2 · response
Published 2 February 2026
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 all women of childbearing age taking ARB medicines and add prescription alerts advising immediate cessation and GP consultation if pregnancy occurs.

Verbatim wording from the response
“1. I reviewed all women of childbearing age taking Candesartan and indeed taking any ARB medication.”

Source location
Response from Riverview Surgery
Page 5 · response
Published 2 February 2026
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
Use reception tasks to trigger pregnancy coding, midwife referral checks and medication reviews, with duty-GP cover when unavailable.

Verbatim wording from the response
“1. Any patient who advises that they have become pregnant will be alerted to myself via a task from reception so that I can; a. Code that they are currently pregnant, b. Request referral to our Community Midwife and c. Conduct a medication review. If I am unavailable the task will be sent to the on/call GP, all clinicians have been briefed as to the dangers of Candesartan.”

Source location
Response from Riverview Surgery
Page 5 · response
Published 2 February 2026
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
Increase reviews of women of childbearing age prescribed ARB medicines from six-monthly to three-monthly.

Verbatim wording from the response
“3. As set out in the SEA, a review of all female patients of child bearing age who are prescribed ARB medication was to be undertaken every 6 months and an alert added to their prescription to stop taking this medication if they become pregnant and to speak to their GP. The frequency of this review has now been increased to 3-monthly in light of the risks of this medication in later pregnancy. In addition, as most prescriptions are now electronic rather than paper copies, the alert will be added to the prescribing instructions section so that it is clearly shown on the label printed for the patient’s medication by the pharmacy when they collect their medication.”

Source location
Response from Riverview Surgery
Page 2 · response
Published 2 February 2026
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
Warn women taking Candesartan or other ARB medicines about pregnancy risks and the need to stop immediately if pregnancy occurs.

Verbatim wording from the response
“3. Opportunistically all women taking Candesartan or any ARB of childbearing age are verbally warned as to the medication dangers and are advised to stop immediately if they become pregnant.”

Source location
Response from Riverview Surgery
Page 5 · response
Published 2 February 2026
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
Implement and apply an SOP covering pregnancy-related safety checks for new medicines, including stopping or replacing medicines unsafe in pregnancy.

Verbatim wording from the response
“1. An SOP has been implemented in relation to prescribing medication to women of child bearing age (15-55 years old). I attach the SOP. A clinical practice meeting has been arranged for 26 February 2026 at which the SOP will be discussed and laminated copies distributed.”

Source location
Response from Riverview Surgery
Page 1 · response
Published 2 February 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Manually reviewing every repeat medication request and creating linked pregnancy alerts is impractical due to workload and lack of technical IT skills.

Verbatim wording from the response
“I have also considered further whether it is possible to identify or flag a pregnant patient when they request repeat medication. This would be an important safeguard for doctors reviewing the two hundred or so repeat medication requests received on a daily basis. Due to their volume and the other priorities for clinicians’ time, it is not practical for the doctor to review each patient’s records when authorising every request. We do not have the technical IT skills at the practice to make changes to the computerised records system and I have therefore contacted our system provider EMIS to ask for their advice and input on whether it is possible, and if so how, to introduce a flag which would identify the pregnancy coding on the patient’s record and link it to the repeat prescriptions for the patient (and ideally include the BNF advice for that medication as well).”

Source location
Response from Riverview Surgery
Page 2 · response
Published 2 February 2026
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 raised6

Lack of advice about medication risks when considering having a child

Candesartan remaining available on repeat prescription during pregnancy

Failure to provide specific advice to stop Candesartan and identify its pregnancy risk

Failure to provide additional medication safety advice during antenatal care

Failure to conduct a detailed review of repeat prescription requests

Lack of system warnings identifying pregnancy during repeat prescribing

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.6

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 6

Respondent positions 1