Swanage Medical Practice

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First report 9 Aug 2022•Latest report 9 Aug 2022

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
Published responses: 100%
Concerns addressed: 5
Stated actions: 3

Concerns and recipient responses

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

9 Aug2022
Dorset
Concerns raised7
1. Lack of a policy for patients prescribed medication while consuming alcohol to excess
2. Lack of a documented process for promptly bringing medication-use concerns to the patient’s attention
3. Lack of defined advice for patients assessed via another healthcare worker instead of face to face
1. Unavailability of the policy to all healthcare staff in the surgery
2. Lack of provision for a follow-up face-to-face medication review
3. Failure to define safe medication amounts and dosages in these circumstances
4. Risk of death from combined use of medication and excess alcohol
Actions described in response 2
1. Action
  Create an electronic-record alert for drugs in the specified prescribing group, warning prescribers about dosage and alcohol-related risks.
2. Action
  Discuss prescribing quantities and patient disengagement at a Significant Event Meeting.
AI-generated summary

Mathew Christopher Moore · 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

Mathew Christopher Moore died on 7 August 2021 in Bournemouth, Dorset, having attached a rope as a ligature. The report records concerns about the combined use of prescribed medication and excess alcohol, including potentially unsafe prescribing, a lack of documented communication of concerns to Mr Moore, and the need for clearer policies, dosage review, follow-up, and information-sharing within the surgery.

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 Swanage Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Lack of a policy for patients prescribed medication while consuming alcohol to excess
Wider context from the report
“2. I have concerns with regard to the following: i. There could be the death of a person in the future due to combined use of ████████ and excess alcohol and I request that consideration is given to creating a policy at the surgery to cover patients who are prescribed ████████, at the same time as consuming alcohol to excess. ii. I would request consideration is given as to the advice to be given in the circumstances where a patient is not being seen face to face, but via another healthcare worker. iii. Further, consideration should be given to the amount and dosage that should be prescribed in these circumstances and whether there should be a documented process to highlight any concerns about the use of ████████ being brought to the patient’s attention as soon as possible. iv. I would request consideration is given that within the policy there is provision for a follow up face to face meeting to review the medication. v. I would request consideration is given to the policy being available to all healthcare staff in the surgery. ”
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 Swanage Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Lack of a documented process for promptly bringing medication-use concerns to the patient’s attention
Wider context from the report
“2. I have concerns with regard to the following: i. There could be the death of a person in the future due to combined use of ████████ and excess alcohol and I request that consideration is given to creating a policy at the surgery to cover patients who are prescribed ████████, at the same time as consuming alcohol to excess. ii. I would request consideration is given as to the advice to be given in the circumstances where a patient is not being seen face to face, but via another healthcare worker. iii. Further, consideration should be given to the amount and dosage that should be prescribed in these circumstances and whether there should be a documented process to highlight any concerns about the use of ████████ being brought to the patient’s attention as soon as possible. iv. I would request consideration is given that within the policy there is provision for a follow up face to face meeting to review the medication. v. I would request consideration is given to the policy being available to all healthcare staff in the surgery. ”
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 Swanage Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Lack of defined advice for patients assessed via another healthcare worker instead of face to face
Wider context from the report
“2. I have concerns with regard to the following: i. There could be the death of a person in the future due to combined use of ████████ and excess alcohol and I request that consideration is given to creating a policy at the surgery to cover patients who are prescribed ████████, at the same time as consuming alcohol to excess. ii. I would request consideration is given as to the advice to be given in the circumstances where a patient is not being seen face to face, but via another healthcare worker. iii. Further, consideration should be given to the amount and dosage that should be prescribed in these circumstances and whether there should be a documented process to highlight any concerns about the use of ████████ being brought to the patient’s attention as soon as possible. iv. I would request consideration is given that within the policy there is provision for a follow up face to face meeting to review the medication. v. I would request consideration is given to the policy being available to all healthcare staff in the surgery. ”
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 Swanage Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of the policy to all healthcare staff in the surgery
Wider context from the report
“2. I have concerns with regard to the following: i. There could be the death of a person in the future due to combined use of ████████ and excess alcohol and I request that consideration is given to creating a policy at the surgery to cover patients who are prescribed ████████, at the same time as consuming alcohol to excess. ii. I would request consideration is given as to the advice to be given in the circumstances where a patient is not being seen face to face, but via another healthcare worker. iii. Further, consideration should be given to the amount and dosage that should be prescribed in these circumstances and whether there should be a documented process to highlight any concerns about the use of ████████ being brought to the patient’s attention as soon as possible. iv. I would request consideration is given that within the policy there is provision for a follow up face to face meeting to review the medication. v. I would request consideration is given to the policy being available to all healthcare staff in the surgery. ”
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 Swanage Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Lack of provision for a follow-up face-to-face medication review
Wider context from the report
“2. I have concerns with regard to the following: i. There could be the death of a person in the future due to combined use of ████████ and excess alcohol and I request that consideration is given to creating a policy at the surgery to cover patients who are prescribed ████████, at the same time as consuming alcohol to excess. ii. I would request consideration is given as to the advice to be given in the circumstances where a patient is not being seen face to face, but via another healthcare worker. iii. Further, consideration should be given to the amount and dosage that should be prescribed in these circumstances and whether there should be a documented process to highlight any concerns about the use of ████████ being brought to the patient’s attention as soon as possible. iv. I would request consideration is given that within the policy there is provision for a follow up face to face meeting to review the medication. v. I would request consideration is given to the policy being available to all healthcare staff in the surgery. ”
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 Swanage Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Failure to define safe medication amounts and dosages in these circumstances
Wider context from the report
“2. I have concerns with regard to the following: i. There could be the death of a person in the future due to combined use of ████████ and excess alcohol and I request that consideration is given to creating a policy at the surgery to cover patients who are prescribed ████████, at the same time as consuming alcohol to excess. ii. I would request consideration is given as to the advice to be given in the circumstances where a patient is not being seen face to face, but via another healthcare worker. iii. Further, consideration should be given to the amount and dosage that should be prescribed in these circumstances and whether there should be a documented process to highlight any concerns about the use of ████████ being brought to the patient’s attention as soon as possible. iv. I would request consideration is given that within the policy there is provision for a follow up face to face meeting to review the medication. v. I would request consideration is given to the policy being available to all healthcare staff in the surgery. ”
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 Swanage Medical Practice; that does not assign responsibility.
PFD Monitor interpretation
Risk of death from combined use of medication and excess alcohol
Wider context from the report
“2. I have concerns with regard to the following: i. There could be the death of a person in the future due to combined use of ████████ and excess alcohol and I request that consideration is given to creating a policy at the surgery to cover patients who are prescribed ████████, at the same time as consuming alcohol to excess. ii. I would request consideration is given as to the advice to be given in the circumstances where a patient is not being seen face to face, but via another healthcare worker. iii. Further, consideration should be given to the amount and dosage that should be prescribed in these circumstances and whether there should be a documented process to highlight any concerns about the use of ████████ being brought to the patient’s attention as soon as possible. iv. I would request consideration is given that within the policy there is provision for a follow up face to face meeting to review the medication. v. I would request consideration is given to the policy being available to all healthcare staff in the surgery. ”
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
Create an electronic-record alert for drugs in the specified prescribing group, warning prescribers about dosage and alcohol-related risks.

Verbatim wording from the response
“In response to Mr Nicholls concerns and suggestions of the 9th August, I can also confirm that we have now created a protocol alert that triggers on the patient electronic record when any drugs in the ████████ prescribing group are issued. This alert warns the prescriber to consider the amount and dosage being prescribed, and highlights the risk of the use of the drug combined with excess alcohol use. The alert also asks them to consider arranging a face to face medication review with the patient. This alert is available to all staff at the Practice who issue medications in the ████████ prescribing group.”

Source location
Response from Swanage Medical Practice
Page 1 · response
Published 30 September 2022
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
Discuss prescribing quantities and patient disengagement at a Significant Event Meeting.

Verbatim wording from the response
“As you will be aware, this incident has been discussed at a Significant Event Meeting at the Practice, where the GPs considered the amount of ████████ prescribed in such cases and also the difficulty where patients fail to engage with GP and Mental Health services.”

Source location
Response from Swanage Medical Practice
Page 1 · response
Published 30 September 2022
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 raised7

Lack of a policy for patients prescribed medication while consuming alcohol to excess

Lack of a documented process for promptly bringing medication-use concerns to the patient’s attention

Lack of defined advice for patients assessed via another healthcare worker instead of face to face

Unavailability of the policy to all healthcare staff in the surgery

Lack of provision for a follow-up face-to-face medication review

Failure to define safe medication amounts and dosages in these circumstances

Risk of death from combined use of medication and excess alcohol

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.2

Actions described in response 2