Recipient

Takeda UK Limited

First report 19 Jan 2016•Latest report 19 Jan 2016

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. 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: 1
Stated actions: 1

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

1stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

19 Jan2016
Manchester South
Concerns raised7
1. Failure to define the terms “prolonged” and “hot” in the hot-bath warning
2. Failure to reconcile prescribed opiate patches with the patient’s actual possession
3. Failure to maintain clear and sufficiently detailed electronic clinical notes
1. Failure to provide a full report of the patient’s care
2. Provision of potentially dangerous bath-removal advice for exhausted Matrifen patches
3. Failure to prominently communicate the danger of taking a hot bath whilst wearing the patch
4. Lack of liaison with the GP Practice over regulation of additional opiate pain-control
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Irene Anne Pearson · 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

Irene Anne Pearson had terminal colon cancer that had spread to other organs and was receiving palliative Matrifen patches. On 19 July 2015, she was found dead in a hot bath at home, apparently still wearing the patch; the stated medical cause of death included opiate toxicity. Concerns included warnings about hot baths and patch removal, advice and communication about opiate medication, unclear prescribing records, and the adequacy of information supplied by the GP practice to the Coroner.

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 Takeda UK Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to define the terms “prolonged” and “hot” in the hot-bath warning
Wider context from the report
“2. Even when the said warning phrase is reached in the leaflet, it then refers to “a prolonged hot bath” without in any way defining the words “prolonged” or “hot”. These terms are easily open to subjective interpretation, which may lead to an unsafe usage environment. (Takeda UK) ”
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 Takeda UK Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to reconcile prescribed opiate patches with the patient’s actual possession
Wider context from the report
“5. The GP Practice’s electronic notes of the attendances upon the patient were unclear and there appeared to be discrepancies between what was noted as prescribed by way of opiate patches, and what the patient actually had in her possession. The notes were on occasions ‘scanty’ in detail and the doctor giving evidence accepted this and told me that this was because they, as doctors, are limited to ten-minute appointments and they do not always have time properly to record their notes. (Churchgate 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 Takeda UK Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain clear and sufficiently detailed electronic clinical notes
Wider context from the report
“5. The GP Practice’s electronic notes of the attendances upon the patient were unclear and there appeared to be discrepancies between what was noted as prescribed by way of opiate patches, and what the patient actually had in her possession. The notes were on occasions ‘scanty’ in detail and the doctor giving evidence accepted this and told me that this was because they, as doctors, are limited to ten-minute appointments and they do not always have time properly to record their notes. (Churchgate 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 Takeda UK Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide a full report of the patient’s care
Wider context from the report
“6. When HM Coroner asks for a full report of the care of the patient from the General Practitioner, it is insufficient (as in this case), for the practice simply to photocopy part of the patient’s records. (Churchgate 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 Takeda UK Limited; that does not assign responsibility.
PFD Monitor interpretation
Provision of potentially dangerous bath-removal advice for exhausted Matrifen patches
Wider context from the report
“3. I heard evidence that the Macmillan Nurses had advised the deceased to take a bath when preparing to remove the ‘exhausted’ patch so as to aid removal. The toxicologist point out that even when due for changing the patch contains (and therefore can release) a very considerable level of the drug. The advice to use this method of removal would therefore be inherently potentially dangerous.(Macmillan Cancer Care) ”
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 Takeda UK Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to prominently communicate the danger of taking a hot bath whilst wearing the patch
Wider context from the report
“1. The package leaflet of advice on the use of Matrifen is very extensive running to several pages of closely printed words. It is not until half way down the eighth page (and then contained in the middle of a 4th bullet point) that there is reference to the danger of taking a hot bath whilst wearing the patch. The Forensic Consultant Toxicologist gave evidence to me that heating of the body will cause an onrush of the delivery of the drug. (Takeda UK) ”
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 Takeda UK Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of liaison with the GP Practice over regulation of additional opiate pain-control
Wider context from the report
“4. I was told that the Macmillan Nurses will prescribe additional opiate pain-control, but there seemed little or no liaison with the GP Practice as to the regulation of this.(Macmillan Cancer Care) ”
Open source report

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

Failure to define the terms “prolonged” and “hot” in the hot-bath warning

Failure to reconcile prescribed opiate patches with the patient’s actual possession

Failure to maintain clear and sufficiently detailed electronic clinical notes

Failure to provide a full report of the patient’s care

Provision of potentially dangerous bath-removal advice for exhausted Matrifen patches

Failure to prominently communicate the danger of taking a hot bath whilst wearing the patch

Lack of liaison with the GP Practice over regulation of additional opiate pain-control