Recipient

Royal College of General Practitioners

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First report 25 Sep 2013•Latest report 30 Mar 2026

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Health professional body. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
36

Naming this recipient

Published responses
89%

Found for named reports

Concerns addressed
53

Across all linked responses

Stated actions
84

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.

89%published responses found
84stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Royal College of General Practitioners linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Mid Kent and Medway

    AI-generated summary

    LUKE OWEN JACKSON · 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

    Luke Owen Jackson, who had Becker’s Muscular Dystrophy and a chest infection, was admitted to hospital on 4 December 2019 and suffered a cardiac arrest on 6 December before being transferred to the Evelina Children’s Hospital. He later died on palliative care from hypoxic ischaemic encephalopathy following prolonged cardiac arrest. The principal concerns included recognition and treatment of total-body potassium depletion in a child with myopathy, and the limitations of monitoring oxygen saturation when assessing deterioration.

    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Oxygen-saturation monitoring failing to detect deterioration when oxygen levels do not deplete

    Wider context from the report

    “The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children’s hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell. They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect vital organs such as the brain and heart. (1) Luke had complex needs and was awaiting results of genetic testing confirmed as Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools and vomiting that had progressed over a five-day period in a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium. (2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they get almost 2000 referrals a year and many have diarrhoea and vomiting as a first symptom. Issues relating to metabolic derangement in a child with myopathies is not always recognised as total body potassium depletion and that treatment may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks: (i) Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell. (ii) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate. (iii) A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk. (iv) Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress. (v) As Luke was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate treatment of total body potassium depletion with gastroenteritis resuscitation

    Wider context from the report

    “The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children’s hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell. They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect vital organs such as the brain and heart. (1) Luke had complex needs and was awaiting results of genetic testing confirmed as Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools and vomiting that had progressed over a five-day period in a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium. (2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they get almost 2000 referrals a year and many have diarrhoea and vomiting as a first symptom. Issues relating to metabolic derangement in a child with myopathies is not always recognised as total body potassium depletion and that treatment may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks: (i) Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell. (ii) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate. (iii) A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk. (iv) Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress. (v) As Luke was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise total body potassium depletion in unwell children with myopathies

    Wider context from the report

    “The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children’s hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell. They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect vital organs such as the brain and heart. (1) Luke had complex needs and was awaiting results of genetic testing confirmed as Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools and vomiting that had progressed over a five-day period in a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium. (2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they get almost 2000 referrals a year and many have diarrhoea and vomiting as a first symptom. Issues relating to metabolic derangement in a child with myopathies is not always recognised as total body potassium depletion and that treatment may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks: (i) Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell. (ii) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate. (iii) A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk. (iv) Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress. (v) As Luke was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Atypical presentation of respiratory distress in children with myopathies weakened by low potassium

    Wider context from the report

    “The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children’s hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell. They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect vital organs such as the brain and heart. (1) Luke had complex needs and was awaiting results of genetic testing confirmed as Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools and vomiting that had progressed over a five-day period in a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium. (2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they get almost 2000 referrals a year and many have diarrhoea and vomiting as a first symptom. Issues relating to metabolic derangement in a child with myopathies is not always recognised as total body potassium depletion and that treatment may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks: (i) Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell. (ii) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate. (iii) A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk. (iv) Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress. (v) As Luke was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest ”
    Open source report

  2. Nottinghamshire

    AI-generated summary

    James Frankish · 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

    James Frankish died at Beeches Residential Home after vomiting plant material and expelling a hard plant mass from his stomach into his oesophagus, causing sudden obstruction. The principal concerns were that professionals and care staff did not fully understand or manage the dangers of Pica, and that national or professional guidance was lacking on identifying, assessing and managing Pica and monitoring for bezoar development.

    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of professionals caring for people with Pica to understand its health risks

    Wider context from the report

    “(1) Professionals who cared for James did not understand how dangerous Pica can be, ie that it carries significant health risks, including the development of a bezoar. This included the GP, Paediatrician, Psychiatrist, Speech and language therapist, Clinical Psychologist. ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of national or professional guidance on identification, assessment and management of Pica and its risks

    Wider context from the report

    “(2) That there is no national or professional guidance about identification, assessment and management of Pica, with no guidance about how best to understand and manage risk in this condition ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of national or professional guidance for monitoring bezoar development in people with Pica

    Wider context from the report

    “(3) That there is no national or professional guidance for monitoring for the possible development of a bezoar in an individual who has Pica. ”
    Open source report

  3. Berkshire

    AI-generated summary

    Mrs Violet Levine Nelson · 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

    Mrs Violet Nelson collapsed suddenly at home and died on 17 September 2016; a post-mortem examination identified a ruptured thoracic aortic aneurysm. The report raised concerns that earlier ultrasound findings were not overseen by a Consultant Radiologist and did not recommend referral to a Vascular Surgeon or CT examination, and that GPs may not have been aware of the significance of a suprarenal aortic aneurysm.

    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to oversee or verify ultrasonography reports by a Consultant Radiologist

    Wider context from the report

    “(1) If the reports of Ultrasonography in 2012, 2013 and 2014 had been overseen/verified by a Consultant Radiologist, it is likely that referral of Mrs Nelson to a Vascular Surgeon and CT examination of the chest would have prompted an appropriate response by the referring GP. (2) It is more likely than not that General Practitioners are not aware of the fact that the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a larger Thoracic Aortic Aneurysm and that, in consequence, CT examination of the chest should be performed or the patient should be referred to a Vascular Surgeon. (3) Therefore, without an ultrasound report carrying an appropriate recommendation to the referring Clinician and if General Practitioners are not made aware of the fact the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a large Thoracic Aortic Aneurysm requiring further investigation, similar deaths to that suffered by Mrs Nelson may occur in the future. ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Ultrasound reports failing to carry appropriate recommendations to referring clinicians

    Wider context from the report

    “(1) If the reports of Ultrasonography in 2012, 2013 and 2014 had been overseen/verified by a Consultant Radiologist, it is likely that referral of Mrs Nelson to a Vascular Surgeon and CT examination of the chest would have prompted an appropriate response by the referring GP. (2) It is more likely than not that General Practitioners are not aware of the fact that the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a larger Thoracic Aortic Aneurysm and that, in consequence, CT examination of the chest should be performed or the patient should be referred to a Vascular Surgeon. (3) Therefore, without an ultrasound report carrying an appropriate recommendation to the referring Clinician and if General Practitioners are not made aware of the fact the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a large Thoracic Aortic Aneurysm requiring further investigation, similar deaths to that suffered by Mrs Nelson may occur in the future. ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of General Practitioner awareness that a supra-renal aortic aneurysm finding may indicate a larger thoracic aortic aneurysm requiring further investigation

    Wider context from the report

    “(1) If the reports of Ultrasonography in 2012, 2013 and 2014 had been overseen/verified by a Consultant Radiologist, it is likely that referral of Mrs Nelson to a Vascular Surgeon and CT examination of the chest would have prompted an appropriate response by the referring GP. (2) It is more likely than not that General Practitioners are not aware of the fact that the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a larger Thoracic Aortic Aneurysm and that, in consequence, CT examination of the chest should be performed or the patient should be referred to a Vascular Surgeon. (3) Therefore, without an ultrasound report carrying an appropriate recommendation to the referring Clinician and if General Practitioners are not made aware of the fact the Ultrasonography finding of an Aneurysm of the Supra-renal Aorta is likely to indicate the presence of a large Thoracic Aortic Aneurysm requiring further investigation, similar deaths to that suffered by Mrs Nelson may occur in the future. ”
    Open source report

    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

    Local hospital radiology and vascular surgery departments determine referral thresholds for suprarenal aortic aneurysms.

    Verbatim wording from the response

    “Dr Matt Houghton, Medical Director of the Clinical Innovation and Research Centre in the RCGP understands that the cut-offs for referrals for the size of a suprarenal aortic abdominal aneurysm (AAA) after ultrasound is usually determined locally in the hospital between the local radiology department and the local vascular surgeons. It may be worth asking the Royal Berkshire Hospital Reading for their protocol during the time period the ultrasound scans took”

    Source location

    2017-0356-Response-by-RCGP
    Page 1 · response
    Published 11 February 2018

    Open published response

  4. Exeter and Greater Devon

    AI-generated summary

    Carly Marie GORDON · 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

    Carly Marie GORDON was admitted to hospital after a failed attempt on her own life and was later found hanging at home on 27 May 2016 after being discharged to her mother's care. The inquest concluded that she took her own life while suffering from depressive disorder and benzodiazepine withdrawal; concerns related to the long-term prescribing and review of benzodiazepines.

    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to review patients receiving extended-term medication for suitability of continued long-term use

    Wider context from the report

    “(2) All patients who receive this drug for an extended period of time should be reviewed by their medical advisors to reassess their suitability for the long term use of this particular medication. ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to prescribe longer-acting rather than shorter-acting benzodiazepines for long-term use

    Wider context from the report

    “(1) The long term use of shorter acting Benzodiazepine instead of longer acting Benzodiazepine in accordance with the British Association of Psychopharmacology Guidelines should be followed when patients are prescribed this drug to avoid dependence. ”
    Open source report

  5. Swansea and Neath Port Talbot

    AI-generated summary

    Patricia Margaret Thomas · 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

    Patricia Margaret Thomas died at Morriston Hospital on 30 October 2013 after suffering an intracerebral haemorrhage, following an episode of unresponsiveness and left-sided weakness. The report identified a potential interaction between Miconazole Gel and Warfarin, a lack of awareness of this interaction among health professionals, and possible difficulties locating clear interaction-checking resources.

    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Potential for Miconazole Gel and Warfarin interaction causing increased blood clotting time and INR

    Wider context from the report

    “It became apparent in the course of the evidence that (1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding. (2) There is a significant lack of knowledge of the interaction among health professionals and/or (3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate. ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of knowledge of the Miconazole Gel and Warfarin interaction among health professionals

    Wider context from the report

    “It became apparent in the course of the evidence that (1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding. (2) There is a significant lack of knowledge of the interaction among health professionals and/or (3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate. ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear or difficult-to-locate resources for checking the Miconazole Gel and Warfarin interaction

    Wider context from the report

    “It became apparent in the course of the evidence that (1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding. (2) There is a significant lack of knowledge of the interaction among health professionals and/or (3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate. ”
    Open source report

  6. Swansea and Neath Port Talbot

    AI-generated summary

    Alan Vaughan 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

    Alan Vaughan Jones had Addison’s disease and became unable to take his steroid medication after developing gastroenteritis. His condition deteriorated, and he died at 08.50 hours on 8 April 2011; the inquest concluded that Addison’s Disease resulted from neglect. Concerns included inadequate training in the use of electronic patient-record software and failures of the software to highlight important diagnosed conditions as alerts.

    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of software programs to provide interruptive alerts for important diagnosed conditions

    Wider context from the report

    “(2) An apparent failure in the software programs themselves to highlight important diagnosed conditions as an alert, when the patient record is opened and to prevent any further steps being taken to navigate the program (and make any entries) without consciously closing the “alert” first. ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of adequate training on the use of electronic software systems

    Wider context from the report

    “(1) An apparent lack of adequate training on the use of the software systems. This meant that important clinical information could not be made available easily. The expert GP gave evidence that this training deficit was not uncommon. He had the experience of using 4 different software programs in his career and had identical issues over lack of training. ”
    Open source report

  7. London (West)

    AI-generated summary

    June Lilian Rose · 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

    June Lilian Rose was bed bound and in deteriorating health when she was prescribed fentanyl patches at an excessive dose, which were applied and replaced before the error was discovered. She later died at home on 14 August 2012; the recorded cause of death included bilateral pneumonia, Alzheimer’s disease and fentanyl toxicity. The principal concern was the lack of mandatory national training or refresher training for GPs on prescribing fentanyl and similar morphine-based pain relief medications.

    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of mandatory and regular refresher training for GPs in prescribing fentanyl and similar morphine-based pain relief medications

    Wider context from the report

    “While the prescribing doctor recognised the an error was made in prescribing the fentanyl patches at that level, it became apparent at the inquest that there appears to be little training of GPs on a national level in the prescription of this and other similar morphine based pain relief medications and consequently, a lack of familiarity with the dosage required or appropriate. I heard evidence that although this particular surgery had sought to take steps to prevent this event from reoccurring, I remain concerned that there is no mandatory training or regular refresher training on a national level in the prescribing of these kinds of drugs. ”
    Open source report

  8. Manchester City

    AI-generated summary

    Oliver George Hiscutt · 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

    Oliver George Hiscutt developed a Group A beta-haemolytic streptococcal infection with a retropharyngeal abscess, followed by catastrophic haemorrhage and cardiac arrests; he died on 7 October 2012. The report raised concern that formal paediatric or child-health training is not mandatory for GPs and that exposure to acute paediatrics during GP training is limited.

    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of mandatory formal paediatric training for GPs

    Wider context from the report

    “Currently it is not mandatory for GPs to undertake formal paediatric / child health training. Facing the Future (2011) states that there are currently 10 000 GP trainees in the country and less than 25% of them will undertake any paediatric placement during their training. GP trainees who do undertake a paediatric placement during their training gain a range of educational benefits such as the development of skills in spotting the sick child, specialist management of children with long term conditions and multi disciplinary team working. The Royal College of General Practitioners and the Royal College of Paediatrics and Child Health strongly support all GPs having exposure to acute paediatrics as part of their vocational training. Offering every GP trainee a hospital post in paediatrics within the current 3 year specialty training programme is undeliverable. The Royal College of General Practitioners makes the case that there should be an enhanced 4 year programme of GP training and that all GPs should undertake specialist led paediatric training. Specialist led paediatric training will ensure that future GPs have the skills and experience they need to assess and respond effectively and safely to sick children, to better co-ordinate the care of children with long term conditions and to safeguard those at risk. ”
    Open source report

  9. West Sussex

    AI-generated summary

    Lee Hollman · 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

    Lee Hollman, who had a long history of intermittently severe mental ill-health, died after taking an overdose of Quetiapine, Trazodone and alcohol on 28 February 2014. The report identified concerns about inaccurate and outdated medical records, the repeat-prescription system, and failure to review patients in line with relevant guidelines.

    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of an effective system to issue repeat prescriptions

    Wider context from the report

    “4. The lack of an effective system to issue repeat prescriptions ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain accurate and up-to-date medical records

    Wider context from the report

    “1. Failure to maintain sufficiently accurate and updated medical records 2. Failure to remove Trazodone from the repeat prescription record 3. Failure to delete the ‘old’ dosage of Quetiapine from the relevant medical records ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to review patients within their own guidelines for repeat prescriptions

    Wider context from the report

    “5. Failure to review patients within their own guidelines with regard to repeat prescriptions ”
    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

    Approve a joint RCGP–Royal Pharmaceutical Society statement setting out guidelines for good working relationships between GPs and pharmacists.

    Verbatim wording from the response

    “The tragic death of Lee Hollman highlights the need for GPs and Pharmacists to work closely together.”

    Source location

    2014-0135-Response-by-Royal-College-of-General-Practitioners
    Page 3 · response
    Published 26 March 2014

    Open published response

  10. Manchester South

    AI-generated summary

    Dorothy Townley · 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

    Dorothy Townley sustained burns after spilling tea at home on 28 September 2012; the burns became infected and she was admitted to hospital on 11 October. Despite active treatment, she died on 20 October 2012. Concerns included communication between District Nurses and the GP, limited knowledge and training in burn treatment, inadequate wound assessment documentation, and unclear processes for requesting urgent blood tests.

    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of District Nurse training on treatment of burns

    Wider context from the report

    “4. There was a lack of training for District Nurses on the treatment of burns. ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of District Nurses and the GP to communicate and coordinate wound care visits

    Wider context from the report

    “1. There was a lack of direct communication between the District Nurses and the GP as to exactly what the deceased’s condition was and what was required on visits. There was no consideration given to carrying out joint visits, no communication as to how Mrs Townley’s wound could be examined if there were no dressings available. ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of District Nursing Team knowledge about treatment of burns

    Wider context from the report

    “2. There was a lack of knowledge within the District Nursing Team around the treatment of burns. ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate detail in wound assessment charts for burns

    Wider context from the report

    “3. The wound assessment chart did not assist as it was not as detailed as it should be for burns in order to help chart their progress or deterioration. ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of shared understanding between the GP and District Nurses about requesting urgent blood tests

    Wider context from the report

    “5. There was a lack of understanding between the GP and District Nurses as to how to request urgent blood tests. It was assumed by the GP that his request for a blood test would be treated as urgent and done that day (on 10th); the District Nurses indicated it would only be carried out as ‘urgent’ if requested. ”
    Open source report

  11. Inner South London

    AI-generated summary

    Anna Ulmer Ahmed · 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

    Anna Ulmer Ahmed, aged 30, was assessed by ambulance staff and later by her GP after experiencing chest pain; she died at home a few hours later from sudden adult cardiac death syndrome. The report raised concerns about low awareness of the condition in general practice and a lack of, or limited awareness of, guidelines for urgent referral of patients vulnerable to 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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of awareness of urgent-referral guidelines for patients vulnerable to SAD

    Wider context from the report

    “(1) Possibility of generally low awareness of the condition of SAD in general practice (2) Apparent lack of guidelines or lack of awareness of guidelines available to guide GPs on the circumstances for urgent referral of patients who should be suspected as being vulnerable to SAD. ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Generally low awareness of SAD in general practice

    Wider context from the report

    “(1) Possibility of generally low awareness of the condition of SAD in general practice (2) Apparent lack of guidelines or lack of awareness of guidelines available to guide GPs on the circumstances for urgent referral of patients who should be suspected as being vulnerable to SAD. ”
    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 Royal College of General Practitioners; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of guidelines for urgent referral of patients vulnerable to SAD

    Wider context from the report

    “(1) Possibility of generally low awareness of the condition of SAD in general practice (2) Apparent lack of guidelines or lack of awareness of guidelines available to guide GPs on the circumstances for urgent referral of patients who should be suspected as being vulnerable to SAD. ”
    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

89%
89%All other recipients 58%
0%100%

How actions were described at the time

This respondent
58%17%25%
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