Rosedale Surgery

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First report 8 Jan 2024•Latest report 8 Jan 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

Naming this recipient

Published responses
200%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
2

Described in responses

Concerns and recipient responses

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

  1. Suffolk

    AI-generated summary

    Sarah Julie MITCHELL · 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

    Sarah Julie MITCHELL, who had a history of chronic back pain, medication dependence, and previous overdoses, was found deceased at her residence on 22 September 2022. The post-mortem found multiple drug toxicity from prescribed medication. The principal concerns were that she received 28 days’ worth of medication in less than 48 hours despite known overdose and hoarding risks, and that emergency department staff had no process for accessing relevant medication records and dispensing information.

    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 Rosedale Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to limit medication dispensing in line with overdose-risk controls

    Wider context from the report

    “The provision to Ms. MITCHELL of 28 days’ worth of prescribed medication in less than a 48-hour period (14 days’ worth of medication dispensed on each occasion she was discharged hospital on the 3rd and 4th of August 2022). This occurred at a time when, due to concerns about Ms. MITCHELL hoarding medication and taking an overdose, she was receiving weekly medication prescriptions from her GP to control this risk. The evidence heard at Inquest indicated that there was no process in place whereby accident and emergency staff could access Ms. MITCHELL’s medical records detailing the medication she was receiving and the rationale behind the dispensing regime in place. ”
    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 Rosedale Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of accident and emergency staff access to medication records and dispensing rationale

    Wider context from the report

    “The provision to Ms. MITCHELL of 28 days’ worth of prescribed medication in less than a 48-hour period (14 days’ worth of medication dispensed on each occasion she was discharged hospital on the 3rd and 4th of August 2022). This occurred at a time when, due to concerns about Ms. MITCHELL hoarding medication and taking an overdose, she was receiving weekly medication prescriptions from her GP to control this risk. The evidence heard at Inquest indicated that there was no process in place whereby accident and emergency staff could access Ms. MITCHELL’s medical records detailing the medication she was receiving and the rationale behind the dispensing regime in place. ”
    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

    Change prescriptions to daily dispensing for patients admitted with more than one overdose within three months, until the risk period ends.

    Verbatim wording from the response

    “2. If a patient is admitted with more than 1 overdose within a 3 month period we will change their prescription to daily until they have not to overdose or overdose on their medication.”

    Source location

    Response from Rosedale Surgery
    Page 1 · response
    Published 19 January 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

    Add a Summary Care Record sentence limiting controlled medication following an overdose diagnosis to no more than a 48-hour supply.

    Verbatim wording from the response

    “From now on when a diagnosis of an overdose gets recorded we will add a sentence to give no more controlled medication than is needed for 48 hours, so they can contact the surgery again for a further supply after. This should be visible on the summary care record that the hospital is looking at.”

    Source location

    Response from Rosedale Surgery
    Page 1 · response
    Published 19 January 2024

    Open published response
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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