5 Nov 2018 Name not published · Prevention of Future Deaths report London Inner South
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Concerns raised 6 Failure to examine patients’ past records in full View source Medication prescribing errors involving incorrect doses View source Failure to record clinical presentations, diagnoses, medication-change rationale and attendances View source Failure to provide urgent psychiatric referral when clinically needed View source Failure to inquire into psychiatric history when presentation warrants further inquiry View source Inappropriate prescribing of large medication quantities during an initial medication switch View source See 3 more concerns
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AI-generated summary
Name not published · 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
The deceased died at St Thomas’s Hospital on 22 November 2017 from brain damage sustained after he hanged himself at home on 20 November 2017. Concerns included changes and prescribing of psychiatric and sedative medication, inadequate clinical records and review of past records, failure to make an urgent psychiatric referral, and uncertainty about the medication found after his death and what he had taken.
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× 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 The Broadgate General Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to examine patients’ past records in full
Wider context from the report “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP.
4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose.
5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full .
6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance.
7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017.
8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing.
9. I accepted ████████ opinion on the various issues set out above.
10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when.
” 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 The Broadgate General Practice; that does not assign responsibility.
PFD Monitor interpretation Medication prescribing errors involving incorrect doses
Wider context from the report “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP.
4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose.
5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full.
6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy . The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that . When he attended on 15 November 2017 asking for more medication she made no note of his attendance.
7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017.
8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing.
9. I accepted ████████ opinion on the various issues set out above.
10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when.
” 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 The Broadgate General Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinical presentations, diagnoses, medication-change rationale and attendances
Wider context from the report “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP.
4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose.
5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full.
6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance .
7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017.
8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing.
9. I accepted ████████ opinion on the various issues set out above.
10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when.
” 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 The Broadgate General Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide urgent psychiatric referral when clinically needed
Wider context from the report “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP.
4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose.
5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full.
6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance.
7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral . He said this was the case by 8 November 2017 .
8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing.
9. I accepted ████████ opinion on the various issues set out above.
10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when.
” 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 The Broadgate General Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to inquire into psychiatric history when presentation warrants further inquiry
Wider context from the report “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history . ████████ said that he would have contacted the deceased’s home GP.
4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose.
5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full.
6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance.
7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017.
8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing.
9. I accepted ████████ opinion on the various issues set out above.
10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when.
” 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 The Broadgate General Practice; that does not assign responsibility.
PFD Monitor interpretation Inappropriate prescribing of large medication quantities during an initial medication switch
Wider context from the report “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP.
4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed . He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose .
5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full.
6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance.
7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017.
8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing.
9. I accepted ████████ opinion on the various issues set out above.
10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations