18 Mar 2021 Bruce Lee Houghton · Prevention of Future Deaths report Manchester North
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Concerns raised 2 Failure to complete annual medication reviews View source Failure to ask patients about over-the-counter medication during medication reviews 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. 10
Action
Recruit three additional permanent salaried GPs.
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Action
Participate in monthly multidisciplinary meetings with mental health, social care and other providers, including network pharmacist medication reviews for people of concern.
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Action
Share the medication-review questionnaire with partner practices and Manchester Health and Social Care Partnership for feedback and good-practice dissemination.
View source
Action
Create a standardised medication-review questionnaire prompting enquiries about over-the-counter medicines and supplements at prescribing and annual reviews.
View source
Action
Move to a clinical IT system with integrated prescribing-safety prompts, medication-review prompts and visual reminders.
View source
Action
Create and monthly review an electronic, traffic-light safety net to prioritise health checks and medication reviews for higher-risk mental health patients.
View source
Action
Recall patients with serious mental health conditions for detailed structured medication reviews, with Mental Health Lead oversight and dedicated administrative support.
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Action
Employ a permanent pharmacist with medication-review competency and responsibility for improving the prescribing policy and questionnaire.
View source
Action
Engage Royal College of General Practitioners practice-development support to review Practice processes and planned safety measures.
View source
Action
Include the medication-review questionnaire in the prescribing policy and provide medication-review training for clinical and new staff.
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AI-generated summary
Bruce Lee Houghton · 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
Bruce Lee Houghton died at home on 16 April 2020 from combined drug toxicity, with excess paracetamol likely causing liver damage and accumulation of his other medications. The report states that he had not had his annual medication review, and that these reviews did not ask patients about over-the-counter medicines they purchased in addition to prescribed medication.
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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 Uplands Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to complete annual medication reviews
Wider context from the report “2. The Court heard the deceased had not had his annual medication review . The court heard evidence that at these reviews the patients are not asked about any over the counter medication they may purchase in addition to their prescribed medication.
” 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 Uplands Medical Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to ask patients about over-the-counter medication during medication reviews
Wider context from the report “2. The Court heard the deceased had not had his annual medication review. The court heard evidence that at these reviews the patients are not asked about any over the counter medication they may purchase in addition to their prescribed medication .
” 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 Recruit three additional permanent salaried GPs.
Verbatim wording from the response “10. The medication review questionnaire and when it should be used will be included in the Practice’s prescribing policy and in-house Practice training on conducting a good medication review will be set up which I will lead. I will be assisted by the Practice manager. The first training on this will occur once the new GPs are in post. The training will also be provided for all new staff as part of their induction, and they will be asked to review the Practice’s prescribing policy. The practice aims to share this fully for feedback at the next practice meeting in August 2021 (17th August 2021) with a view to implementing it thereafter.” Source location 2021-0160-Response-from-Uplands-Medical-Practice_Published
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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 Participate in monthly multidisciplinary meetings with mental health, social care and other providers, including network pharmacist medication reviews for people of concern.
Verbatim wording from the response “2. Ms Kearsley specified in the Regulation 28 report that her concern related to the fact that the Court heard that the deceased had not had his annual medication review and that the Court heard evidence that at these reviews the patients were not asked about any over the counter medication they may purchase in addition to their prescribed medication.” Source location 2021-0160-Response-from-Uplands-Medical-Practice_Published
Open published response
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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 Share the medication-review questionnaire with partner practices and Manchester Health and Social Care Partnership for feedback and good-practice dissemination.
Verbatim wording from the response “7. This questionnaire will be shared with the 3 other GP practices that are involved in the multidisciplinary team and will also be shared with Manchester Health and Social care Partnership for their views to see if it can be improved in any way and to promote good practice. I have already liaised with Manchester Health and Social Care Partnership to ask for their support and ████████, Senior Primary care Manager for Quality Improvement across Greater Manchester has informed me she will investigate how they can assist. Once this feedback has been received the Practice will look to embed the questionnaire within the current clinical system (Vision) although due to its limitations this may not be possible until the Practice moves to a new clinical system.” Source location 2021-0160-Response-from-Uplands-Medical-Practice_Published
Open published response
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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 Create a standardised medication-review questionnaire prompting enquiries about over-the-counter medicines and supplements at prescribing and annual reviews.
Verbatim wording from the response “6. The Practice is in the process of creating a standardised medication review template based on good medical practice which will include a prompt to routinely trigger an enquiry as to if the patient is taking any over the counter medication, or supplements at the point of prescribing and at annual reviews. The clinical staff at the practice will all be made aware that they are to complete this questionnaire when prescribing new medication to a patient or when they are conducting a medication review.” Source location 2021-0160-Response-from-Uplands-Medical-Practice_Published
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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 Move to a clinical IT system with integrated prescribing-safety prompts, medication-review prompts and visual reminders.
Verbatim wording from the response “8. The Practice along with all the practices in Bury is in the process of moving to a new clinical IT system and it is our understanding that this has integrated prompts to improve the prescribing safety. This should assist staff who are prescribing in when it is appropriate to conduct a medication review and provide visual reminders. The Practice is due to have the new system in place by March 2022.” Source location 2021-0160-Response-from-Uplands-Medical-Practice_Published
Open published response
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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 Create and monthly review an electronic, traffic-light safety net to prioritise health checks and medication reviews for higher-risk mental health patients.
Verbatim wording from the response “14. The higher risk mental health patients will be invited for a health check first and then subsequently all patients with known mental health conditions will be invited for a medication review. The Practice will aim to complete medication reviews of the higher risk patients with serious mental health conditions by the end of December 2021 with all patients having completed this by March 2022. An electronic document will be created as a safety net to prioritise these patients and reviewed monthly with the support of a mental health champion to ensure the patient has a health check followed by a medication review with a GP or pharmacist. This document will be completed by the end of August 2021, and a traffic light system will be used to identify patients needing urgent, medium, and less urgent reviews in order of priority.” Source location 2021-0160-Response-from-Uplands-Medical-Practice_Published
Open published response
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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 Recall patients with serious mental health conditions for detailed structured medication reviews, with Mental Health Lead oversight and dedicated administrative support.
Verbatim wording from the response “13. As part of the Covid recovery the Practice is in the process of sending out invites as part of the recall system. The Practice will prioritise the completion of a detailed structured medication review for all patients with serious mental health conditions as defined in the Quality Outcomes Framework (QOF). Mr. Houghton would have been included in this group of patients. As the Mental Health Lead for the Practice, I will have oversight of this process. A dedicated member of staff will manage this, and the Practice is looking to train up a mental health champion to support this. We expect to have this in place by the end of August 2021.” Source location 2021-0160-Response-from-Uplands-Medical-Practice_Published
Open published response
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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 Employ a permanent pharmacist with medication-review competency and responsibility for improving the prescribing policy and questionnaire.
Verbatim wording from the response “11. The Practice has employed a permanent pharmacist who is set to join in October 2021, after a thorough competency-based interview which specifically included questions about competency in conducting medication reviews and if they were routinely enquiring about over the counter medications as part of these. This was important to the Practice to ensure the pharmacist understands the goals of the Practice. The permanent pharmacist will then have an influence on the prescribing policy and the medication” Source location 2021-0160-Response-from-Uplands-Medical-Practice_Published
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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 Engage Royal College of General Practitioners practice-development support to review Practice processes and planned safety measures.
Verbatim wording from the response “15. The Practice is engaging the practice development support of the Royal College of GPs to review the Practice processes currently in place and the plans shared above, for feedback and review. I would be happy to provide a further update to the coroner regarding the progress in November 2021 if that is acceptable.” Source location 2021-0160-Response-from-Uplands-Medical-Practice_Published
Open published response
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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 Include the medication-review questionnaire in the prescribing policy and provide medication-review training for clinical and new staff.
Verbatim wording from the response “10. The medication review questionnaire and when it should be used will be included in the Practice’s prescribing policy and in-house Practice training on conducting a good medication review will be set up which I will lead. I will be assisted by the Practice manager. The first training on this will occur once the new GPs are in post. The training will also be provided for all new staff as part of their induction, and they will be asked to review the Practice’s prescribing policy. The practice aims to share this fully for feedback at the next practice meeting in August 2021 (17th August 2021) with a view to implementing it thereafter.” Source location 2021-0160-Response-from-Uplands-Medical-Practice_Published
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 The questionnaire may not be embeddable in the current clinical system because of its limitations, until the Practice moves to a new system.
Verbatim wording from the response “7. This questionnaire will be shared with the 3 other GP practices that are involved in the multidisciplinary team and will also be shared with Manchester Health and Social care Partnership for their views to see if it can be improved in any way and to promote good practice. I have already liaised with Manchester Health and Social Care Partnership to ask for their support and ████████, Senior Primary care Manager for Quality Improvement across Greater Manchester has informed me she will investigate how they can assist. Once this feedback has been received the Practice will look to embed the questionnaire within the current clinical system (Vision) although due to its limitations this may not be possible until the Practice moves to a new clinical system.” Source location 2021-0160-Response-from-Uplands-Medical-Practice_Published
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations