Recipient

The Practice Surgeries Limited

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First report 1 Nov 2013•Latest report 1 Nov 2013

Recipient record

Reports, concerns and published responses

Health and care · Independent healthcare provider. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

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

Reports over time

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. East London

    AI-generated summary

    Joanne Manning · 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

    Joanne Manning had a history of poly-substance abuse and methadone treatment, developed asthma and increasing breathlessness, and died from respiratory failure. The inquest conclusion attributed the respiratory failure to the combination of her respiratory disease, methadone, mirtazapine, cocaine and morphine. Concerns included a failure to provide the methadone-prescribing psychiatrist with information about her diagnosis and treatment, and the absence of a procedure ensuring clear communication between general practice and secondary care methadone providers.

    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 Practice Surgeries Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inappropriate reliance on patients to communicate key clinical information to methadone prescribers

    Wider context from the report

    “(1) Methadone is to be used with caution in a patient suffering from asthma. In order for the prescriber of methadone to exercise all due caution, they would have to be fully informed of the patient’s diagnosis and treatment by other healthcare professionals involved in the patient’s care. (2) Evidence was heard that methadone should be used with caution in a patient who is also receiving mirtazapine. (3) The psychiatrist prescribing the methadone requested further information about the patient’s medication and treatment from The Practice, Loxford. The letter from the psychiatrist was in general practice file. It was not however responded to. (4) The general practitioner who gave evidence at the Inquest agreed that the psychiatrist should have been fully informed, but she felt that the patient could tell the psychiatrist about her diagnosis and treatment. (4) The general practitioner was unable to comment on whether it would be appropriate for a patient who often attended appointments intoxicated, to inform the psychiatrist of key clinical information. It is my view that this would not be appropriate. (5) Evidence was given at the Inquest that there was no procedure or policy in place to ensure clear lines of communication between general practitioners to secondary care providers of methadone. It was agreed by the general practitioner and psychiatrist that such a policy/procedure would be desirable to protect patients in the future. ”
    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 Practice Surgeries Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a procedure or policy ensuring clear communication between general practitioners and secondary care methadone providers

    Wider context from the report

    “(1) Methadone is to be used with caution in a patient suffering from asthma. In order for the prescriber of methadone to exercise all due caution, they would have to be fully informed of the patient’s diagnosis and treatment by other healthcare professionals involved in the patient’s care. (2) Evidence was heard that methadone should be used with caution in a patient who is also receiving mirtazapine. (3) The psychiatrist prescribing the methadone requested further information about the patient’s medication and treatment from The Practice, Loxford. The letter from the psychiatrist was in general practice file. It was not however responded to. (4) The general practitioner who gave evidence at the Inquest agreed that the psychiatrist should have been fully informed, but she felt that the patient could tell the psychiatrist about her diagnosis and treatment. (4) The general practitioner was unable to comment on whether it would be appropriate for a patient who often attended appointments intoxicated, to inform the psychiatrist of key clinical information. It is my view that this would not be appropriate. (5) Evidence was given at the Inquest that there was no procedure or policy in place to ensure clear lines of communication between general practitioners to secondary care providers of methadone. It was agreed by the general practitioner and psychiatrist that such a policy/procedure would be desirable to protect patients in the future. ”
    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 Practice Surgeries Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure methadone prescribers are fully informed of patients’ diagnosis, medication and treatment

    Wider context from the report

    “(1) Methadone is to be used with caution in a patient suffering from asthma. In order for the prescriber of methadone to exercise all due caution, they would have to be fully informed of the patient’s diagnosis and treatment by other healthcare professionals involved in the patient’s care. (2) Evidence was heard that methadone should be used with caution in a patient who is also receiving mirtazapine. (3) The psychiatrist prescribing the methadone requested further information about the patient’s medication and treatment from The Practice, Loxford. The letter from the psychiatrist was in general practice file. It was not however responded to. (4) The general practitioner who gave evidence at the Inquest agreed that the psychiatrist should have been fully informed, but she felt that the patient could tell the psychiatrist about her diagnosis and treatment. (4) The general practitioner was unable to comment on whether it would be appropriate for a patient who often attended appointments intoxicated, to inform the psychiatrist of key clinical information. It is my view that this would not be appropriate. (5) Evidence was given at the Inquest that there was no procedure or policy in place to ensure clear lines of communication between general practitioners to secondary care providers of methadone. It was agreed by the general practitioner and psychiatrist that such a policy/procedure would be desirable to protect patients in the future. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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