Concerns raised 7 Lack of a policy for patients prescribed medication while consuming alcohol to excess View source Lack of a documented process for promptly bringing medication-use concerns to the patient’s attention View source Lack of defined advice for patients assessed via another healthcare worker instead of face to face View source Unavailability of the policy to all healthcare staff in the surgery View source Lack of provision for a follow-up face-to-face medication review View source Failure to define safe medication amounts and dosages in these circumstances View source Risk of death from combined use of medication and excess alcohol View source See 4 more concerns
Responses linked to these concerns
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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
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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
Open published response
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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
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations