The Knoll Surgery

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First report 29 Aug 2014•Latest report 29 Aug 2014

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

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from The Knoll Surgery linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Blackpool and the Fylde

    AI-generated summary

    Stephen James Morris · 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

    Stephen James Morris, who had previously been diagnosed with bipolar affective disorder, was found deceased in the bath at his flat on the morning after 16 June 2013. A post-mortem found high levels of mood-stabilising and antidepressant medication, whose combined effects proved fatal; the inquest concluded that he took his own life. The principal concerns were that Mirtazapine was prescribed despite awareness of his diagnosis and its suitability concerns, based on the patient's verbal account rather than confirmation from the mental health team.

    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 Knoll Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to exchange sufficient relevant mental health information during cross-area transitions

    Wider context from the report

    “Having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because: • I am concerned that there was a limited exchange of information as regards Stephen and his mental health between the mental health professionals in Cheshire and their counterparts in Blackpool. • By the time that Stephen came to Blackpool for what turned out to be the final time the professionals in Blackpool did not have a detailed picture of how Stephen had presented during recent weeks in relation to his mental health. • When individuals with a similar mental health history as Stephen do move from one area of the country to another there is the potential for a mental health team to find themselves with less detailed relevant information than may be the case for a similar individual who has recently been residing within the immediate area. I am concerned that the quality of exchange of information needs to be such that when mental health professionals find themselves dealing with such an individual that they have as much relevant information as possible to be able to assess the risk such a patient poses and to respond accordingly. ”
    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 Knoll Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Prescribing medication that is not preferred for a known mental-health condition without discussion with the responsible mental-health care team

    Wider context from the report

    “Having concluded this inquest, I now write to you to confirm that in my view you should take action because: • I am concerned that medication was prescribed to a Patient you knew had previously been referred to the local hospital Trust in respect of his mental health and the diagnosis that had been made. • That you prescribed the medication on the basis of verbal information provided by the Patient rather than seeking some confirmation from those within the Hospital Trust with responsibility for the Patient's mental health care provision. • That knowing the diagnosis, you prescribed medication you acknowledged was not the preferred medication for this Patient's condition and seemingly in the absence of discussion with those who had responsibility for the Patient’s mental health care. I would therefore be obliged if the Trust would write to me in due course to confirm what steps if any you propose to take to address these concerns. ”
    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 Knoll Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to confirm mental-health treatment information with the responsible hospital care team before prescribing medication

    Wider context from the report

    “Having concluded this inquest, I now write to you to confirm that in my view you should take action because: • I am concerned that medication was prescribed to a Patient you knew had previously been referred to the local hospital Trust in respect of his mental health and the diagnosis that had been made. • That you prescribed the medication on the basis of verbal information provided by the Patient rather than seeking some confirmation from those within the Hospital Trust with responsibility for the Patient's mental health care provision. • That knowing the diagnosis, you prescribed medication you acknowledged was not the preferred medication for this Patient's condition and seemingly in the absence of discussion with those who had responsibility for the Patient’s mental health care. I would therefore be obliged if the Trust would write to me in due course to confirm what steps if any you propose to take to address these concerns. ”
    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

Data last updated 7 September 2026