24 Nov 2023 Zulfiqar HUSSAIN · Prevention of Future Deaths report Manchester North
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Concerns raised 2 Failure to record adverse medication markers on computerised medical records View source Lack of a robust system for bringing potentially actionable correspondence to medical staff attention View source
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. 3
Action
Maintain an electronic medication alert identifying contraindicated or potentially misused medicines and interactions with methadone.
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Action
Update document-management procedures and route high-risk, urgent, medication-change and safeguarding correspondence to the appropriate GP.
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Action
Assign two designated practice staff members responsibility for document management.
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AI-generated summary
Zulfiqar HUSSAIN · 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
Zulfiqar Hussain, who was 48 years old, was found dead at home on 2 April 2023 from combined drug toxicity causing significant respiratory depression, compounded by pneumonia. The report identified concerns that incoming correspondence was not reliably brought to clinicians’ attention and that adverse medication markers were not being added to electronic medical records, creating a risk that contraindicated medicines could be prescribed.
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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 Croft Shifa Health Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to record adverse medication markers on computerised medical records
Wider context from the report “(2) Adverse medication markers are not being placed on computerised medical records and this creates the risk that contraindicated medications may be inadvertently prescribed .
” 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 Croft Shifa Health Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust system for bringing potentially actionable correspondence to medical staff attention
Wider context from the report “(1) As previously raised in Report to Prevent Future Deaths dated 23 December 2021, incoming correspondence to the GP practice continues to be dealt with by administrative staff who decide whether or not it is placed before a GP. The concern is that there is no robust system in place to ensure that communication to the surgery which may require action to be taken by medical staff is brought to their attention .
” 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 Maintain an electronic medication alert identifying contraindicated or potentially misused medicines and interactions with methadone.
Verbatim wording from the response “We conducted an audit on Mr Hussain’s medical records which showed that an alert was added to the records on 10/11/2020 alerting any clinician adding medication that may have potential misuse (including not to add benzodiazepines, opiates and gabapentin/pregabalin) and listing medication that could have an interaction with methadone. I attach an audit trail of this.” Source location Response from The Croft Shifa Health Centre
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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 Update document-management procedures and route high-risk, urgent, medication-change and safeguarding correspondence to the appropriate GP.
Verbatim wording from the response “Our document management was reviewed in November 2021 in response to a Regulation 28 Report issued by the coroner. We had a practice meeting and discussed the process of filing Do Not Attend notifications that were in place for secondary care services as well as screening services and ‘2 week wait’ suspected cancer referrals. We agreed that we would amend the procedure for document management to expand the list to include the below mentioned specialities that would be sent to GP’s, as a result of this incident. Please see attached Significant Event Analysis report.” Source location Response from The Croft Shifa Health Centre
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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 Assign two designated practice staff members responsibility for document management.
Verbatim wording from the response “We have two designated members of staff who are responsible for document management within the practice. The GP’s discussed and informed staff that the below noted patients are ‘high risk’. The Document Management Policy was updated to reflect the changes.” Source location Response from The Croft Shifa Health Centre
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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 The existing computerised medication alert is considered sufficient to identify potentially contraindicated or misused medicines when prescribing.
Verbatim wording from the response “We conducted an audit on Mr Hussain’s medical records which showed that an alert was added to the records on 10/11/2020 alerting any clinician adding medication that may have potential misuse (including not to add benzodiazepines, opiates and gabapentin/pregabalin) and listing medication that could have an interaction with methadone. I attach an audit trail of this.” Source location Response from The Croft Shifa Health Centre
Open published response
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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 Existing document-management procedures, designated staff and GP-routing arrangements are considered sufficient to identify and escalate clinically important correspondence.
Verbatim wording from the response “Our document management was reviewed in November 2021 in response to a Regulation 28 Report issued by the coroner. We had a practice meeting and discussed the process of filing Do Not Attend notifications that were in place for secondary care services as well as screening services and ‘2 week wait’ suspected cancer referrals. We agreed that we would amend the procedure for document management to expand the list to include the below mentioned specialities that would be sent to GP’s, as a result of this incident. Please see attached Significant Event Analysis report.” Source location Response from The Croft Shifa Health Centre
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23 Dec 2021 Sameena Javed · Prevention of Future Deaths report Manchester North
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Concerns raised 1 Lack of a system for identifying and bringing action-requiring correspondence to medical staff View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sameena Javed · 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
Sameena Javed, aged 33, presented to hospital with severe complications of anorexia nervosa, malnutrition and heart failure, and was subsequently found to have COVID-19 pneumonitis. Despite treatment, she deteriorated and died on 30 May 2021. The principal concern was that the GP practice had no written procedure or guidance to ensure correspondence requiring medical action was brought to a GP’s attention.
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 The Croft Shifa Health Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for identifying and bringing action-requiring correspondence to medical staff
Wider context from the report “The Court heard that incoming correspondence to the GP practice is dealt with by administrative staff who are responsible for deciding whether it should be placed before a GP. There is no written procedure or guidance in place at the GP Practice which guides administrative staff on which correspondence needs to be placed before the GP before it is filed within the patient records. The concern is that there is no system in place to ensure that communication to the surgery which requires actions to be taken by the medical staff is brought to their attention .
” 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