Recipient

Roundwell Medical Centre

First report 16 Apr 2014•Latest report 16 Apr 2014

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: 3
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 Roundwell Medical Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

16 Apr2014
Norfolk
Concerns raised3
1. Lack of adequate records of medication discussions
2. Delays in reviewing medication
3. Failure to make a plan for future medication and dose reduction
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Conduct six-monthly reviews for patients receiving long-term benzodiazepines or opiates and document the clinical plan and management discussed.
  Stated planned
2. Action
  Document the full clinical plan and management in records when starting patients on addictive medication.
  Stated planned
3. Action
  Conduct a regular monthly search to identify patients receiving addictive medication who fail to attend appointments.
  Stated planned
1. Action
  Design a bespoke Addictive Medication Review template to ensure reviews are documented and completed correctly.
  Stated planned
AI-generated summary

KATHRYN LOUISE SAWYER · 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

Kathryn Louise Sawyer, who had a significant history of mental health issues and was prescribed multiple medications including Methadone, was found collapsed and unresponsive at home on 14 August 2013 and died shortly after arriving at hospital. The medical cause of death was respiratory failure due to an overdose of Methadone in combination with therapeutic levels of other drugs. A principal concern was that, although her medication was reviewed in June 2013, there was no or no detailed record of the discussion and no plan for future medication, particularly any plan to decrease it.

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 Roundwell Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Lack of adequate records of medication discussions
Wider context from the report
“(1) Mrs Sawyer registered with the Roundwell Surgery in July 2012 at which time she was known to be addicted to Chloral Betaine (she was prescribed double the dosage recommended in the BNF) and was prescribed a number of different additional medications, including Methadone (prescribed by Trust Alcohol and Drug Service); (2) She attended the Surgery with a letter from her previous GP expressing Mrs Sawyers' concerns about her medication being decreased. It was felt sensible to allow her to feel comfortable with the Surgery before consideration was given to the medication and amounts she was being prescribed. This is accepted as reasonable. (3) During the course of the next 13 months Mrs Sawyer was seen by the Practice on a regular basis when her medication was varied and/or increased. She was admitted to Hospital in November 2012 as a result of an overdose. (4) Mrs Sawyer’s mental health condition stabilised in Spring 2013 when she attended the Surgery for physical problems only. (5) Her medication was not reviewed by the Surgery until June 2013. It was then reviewed by a Locum Doctor. There is no or no detailed record of the discussion relating to her medication and no plan made between patient and the surgery with regard to future medication and in particular any plan to decrease. ”
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 Roundwell Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Delays in reviewing medication
Wider context from the report
“(1) Mrs Sawyer registered with the Roundwell Surgery in July 2012 at which time she was known to be addicted to Chloral Betaine (she was prescribed double the dosage recommended in the BNF) and was prescribed a number of different additional medications, including Methadone (prescribed by Trust Alcohol and Drug Service); (2) She attended the Surgery with a letter from her previous GP expressing Mrs Sawyers' concerns about her medication being decreased. It was felt sensible to allow her to feel comfortable with the Surgery before consideration was given to the medication and amounts she was being prescribed. This is accepted as reasonable. (3) During the course of the next 13 months Mrs Sawyer was seen by the Practice on a regular basis when her medication was varied and/or increased. She was admitted to Hospital in November 2012 as a result of an overdose. (4) Mrs Sawyer’s mental health condition stabilised in Spring 2013 when she attended the Surgery for physical problems only. (5) Her medication was not reviewed by the Surgery until June 2013. It was then reviewed by a Locum Doctor. There is no or no detailed record of the discussion relating to her medication and no plan made between patient and the surgery with regard to future medication and in particular any plan to decrease. ”
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 Roundwell Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to make a plan for future medication and dose reduction
Wider context from the report
“(1) Mrs Sawyer registered with the Roundwell Surgery in July 2012 at which time she was known to be addicted to Chloral Betaine (she was prescribed double the dosage recommended in the BNF) and was prescribed a number of different additional medications, including Methadone (prescribed by Trust Alcohol and Drug Service); (2) She attended the Surgery with a letter from her previous GP expressing Mrs Sawyers' concerns about her medication being decreased. It was felt sensible to allow her to feel comfortable with the Surgery before consideration was given to the medication and amounts she was being prescribed. This is accepted as reasonable. (3) During the course of the next 13 months Mrs Sawyer was seen by the Practice on a regular basis when her medication was varied and/or increased. She was admitted to Hospital in November 2012 as a result of an overdose. (4) Mrs Sawyer’s mental health condition stabilised in Spring 2013 when she attended the Surgery for physical problems only. (5) Her medication was not reviewed by the Surgery until June 2013. It was then reviewed by a Locum Doctor. There is no or no detailed record of the discussion relating to her medication and no plan made between patient and the surgery with regard to future medication and in particular any plan to decrease. ”
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
Conduct six-monthly reviews for patients receiving long-term benzodiazepines or opiates and document the clinical plan and management discussed.

Verbatim wording from the response
“4. All patients on long term medication of Benzodiazepines and Opiates will have a six month medication review which will document the clinical plan/ management discussed with the patient. Action – immediate”

Source location
2014-0177-Response-by-Roundwell-Medical-Centre
Page 1 · response
Published 16 April 2014
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
Document the full clinical plan and management in records when starting patients on addictive medication.

Verbatim wording from the response
“2. For patients being put on addictive medication, the GP will ensure that the clinical plan / management is fully detailed in the patients’ medical records. Action – immediate”

Source location
2014-0177-Response-by-Roundwell-Medical-Centre
Page 1 · response
Published 16 April 2014
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
Conduct a regular monthly search to identify patients receiving addictive medication who fail to attend appointments.

Verbatim wording from the response
“11. Concerns were noted for those patients on addictive medication who failed to attend appointments. Agreed a regular search would be completed to identify patients and relevant action to be taken. Action – regular monthly search.”

Source location
2014-0177-Response-by-Roundwell-Medical-Centre
Page 2 · response
Published 16 April 2014
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
Design a bespoke Addictive Medication Review template to ensure reviews are documented and completed correctly.

Verbatim wording from the response
“6. A bespoke “Addictive Medication Review” template to be designed to ensure that all reviews are documented and completed correctly. Action – within 3 months”

Source location
2014-0177-Response-by-Roundwell-Medical-Centre
Page 2 · response
Published 16 April 2014
Open published response