Recipient

TPP Ltd

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First report 19 Sep 2019•Latest report 23 Mar 2023

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
2

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 TPP Ltd linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Derby and Derbyshire

    AI-generated summary

    Jade Paula REVELL · 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

    Jade Revell died from a sudden cardiac event after being taken to hospital on 25 December 2021, having suffered the event at home. A low potassium result from 27 October 2021 was not communicated to her, resulting in a missed opportunity to treat hypokalaemia and monitor potassium levels. The report raises concerns that the GP computer system may not display all blood results clearly, increasing the risk that abnormal results are missed and not acted upon.

    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 TPP Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the laboratory-results display to show all results in minimised mode

    Wider context from the report

    “The SystemOne computer programme used by the GP Practice can, when a clinician is reviewing the results (blood) from the laboratory with the screen in minimised mode (which is not unusual because of a need to work with a split screen), not show all the results. To do so would need the clinician to scroll down and a scroll feature is not available. This gives rise to the risk of an abnormal result being missed and unactioned. Abnormal (out of range) should be more visible – appear at the top of a list and colour coded to minimise the risk of a result not being seen / missed. The computer programme prevents this. ”
    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 TPP Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make abnormal laboratory results prominent in the display

    Wider context from the report

    “The SystemOne computer programme used by the GP Practice can, when a clinician is reviewing the results (blood) from the laboratory with the screen in minimised mode (which is not unusual because of a need to work with a split screen), not show all the results. To do so would need the clinician to scroll down and a scroll feature is not available. This gives rise to the risk of an abnormal result being missed and unactioned. Abnormal (out of range) should be more visible – appear at the top of a list and colour coded to minimise the risk of a result not being seen / missed. The computer programme prevents this. ”
    Open source report

  2. Suffolk

    AI-generated summary

    Mark Jarvis · 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

    Mark Jarvis was found apparently deceased in his cell at HMP Warren Hill on 30 December 2015 and was later pronounced dead. The inquest concluded that the death resulted from a cardiac event precipitated by ingestion of a New Psychoactive Substance, with ischaemic heart disease recorded as the medical cause of death. Concerns included difficulties with the prison prescription system, including the inability to readily verify current and previous prescriptions, and the potential misuse of medications.

    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 TPP Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a direct link between prescribed medicines and previous diagnoses

    Wider context from the report

    “1. During the course of the inquest a GP who was responsible for medical care at HMP Warren Hill gave evidence in relation to the computer system, SytmOne which was used to review and prescribed medicines to the prisoners at the time of Mark’s death. The court was told that the SystmOne online prescription ‘module’ was not clear to read or easy to understand and appeared incompatible with the prison’s own IT system. The GP described that this left them in the situation of not being sure what a patient had been previously prescribed, not being sure what repeat prescriptions were in place and that they had no way of readily understanding what had been taken by a particular patient or when they were supposed to have taken it. It was also explained that there was no direct link on the system between medications prescribed and previous diagnoses. Due to the time it took to navigate the records it was reported that some GP’s used their experience to identify a previous diagnosis from the repeat prescriptions recorded in the prescription module. The GP further described that removing a prisoner’s prescription from the system when it was no longer necessary was very difficult. One of the contributing factors the jury found to Mark’s death was directly related with poor adherence to his blood pressure medication regime on repeat prescription. Considering the difficulties GPs are facing when using the prescription module, and the testimony given by the GP in this case, it would appear there is no easy system for a doctor to verify exactly what their patient has already been prescribed and whether or not that prescription is still current. Further, in relation to the potential misuse of drugs incorrectly or over-prescribed the GP explained that some medications, such as opioids or anti depression medication (including amitriptyline and sertraline) had ‘currency’ within the prison and it was known they would be traded by some prisoners. Therefore, not being able to readily identify what a prisoner should be, or already is being prescribed at the time of any specific consultation is again clearly a cause for concern. In an interview the GP had with investigators from the Prisons and Probation Ombudsman’s Office on the 30th December 2015 (just one day after Mark’s death) the GP described the prescription module as “an absolute nightmare and we are banging our heads against a brick wall. We’re trying hard to get some changes done because we are concerned about safety” When specifically questioned at the inquest on the 3rd September 2019 the GP stated that the situation as it stood at the end of December 2015 had still not been resolved. ”
    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 TPP Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Difficulty removing no-longer-needed prescriptions from the medication system

    Wider context from the report

    “1. During the course of the inquest a GP who was responsible for medical care at HMP Warren Hill gave evidence in relation to the computer system, SytmOne which was used to review and prescribed medicines to the prisoners at the time of Mark’s death. The court was told that the SystmOne online prescription ‘module’ was not clear to read or easy to understand and appeared incompatible with the prison’s own IT system. The GP described that this left them in the situation of not being sure what a patient had been previously prescribed, not being sure what repeat prescriptions were in place and that they had no way of readily understanding what had been taken by a particular patient or when they were supposed to have taken it. It was also explained that there was no direct link on the system between medications prescribed and previous diagnoses. Due to the time it took to navigate the records it was reported that some GP’s used their experience to identify a previous diagnosis from the repeat prescriptions recorded in the prescription module. The GP further described that removing a prisoner’s prescription from the system when it was no longer necessary was very difficult. One of the contributing factors the jury found to Mark’s death was directly related with poor adherence to his blood pressure medication regime on repeat prescription. Considering the difficulties GPs are facing when using the prescription module, and the testimony given by the GP in this case, it would appear there is no easy system for a doctor to verify exactly what their patient has already been prescribed and whether or not that prescription is still current. Further, in relation to the potential misuse of drugs incorrectly or over-prescribed the GP explained that some medications, such as opioids or anti depression medication (including amitriptyline and sertraline) had ‘currency’ within the prison and it was known they would be traded by some prisoners. Therefore, not being able to readily identify what a prisoner should be, or already is being prescribed at the time of any specific consultation is again clearly a cause for concern. In an interview the GP had with investigators from the Prisons and Probation Ombudsman’s Office on the 30th December 2015 (just one day after Mark’s death) the GP described the prescription module as “an absolute nightmare and we are banging our heads against a brick wall. We’re trying hard to get some changes done because we are concerned about safety” When specifically questioned at the inquest on the 3rd September 2019 the GP stated that the situation as it stood at the end of December 2015 had still not been resolved. ”
    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 TPP Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the prescription system to provide clear, accessible information on patients’ current and previous medicines

    Wider context from the report

    “1. During the course of the inquest a GP who was responsible for medical care at HMP Warren Hill gave evidence in relation to the computer system, SytmOne which was used to review and prescribed medicines to the prisoners at the time of Mark’s death. The court was told that the SystmOne online prescription ‘module’ was not clear to read or easy to understand and appeared incompatible with the prison’s own IT system. The GP described that this left them in the situation of not being sure what a patient had been previously prescribed, not being sure what repeat prescriptions were in place and that they had no way of readily understanding what had been taken by a particular patient or when they were supposed to have taken it. It was also explained that there was no direct link on the system between medications prescribed and previous diagnoses. Due to the time it took to navigate the records it was reported that some GP’s used their experience to identify a previous diagnosis from the repeat prescriptions recorded in the prescription module. The GP further described that removing a prisoner’s prescription from the system when it was no longer necessary was very difficult. One of the contributing factors the jury found to Mark’s death was directly related with poor adherence to his blood pressure medication regime on repeat prescription. Considering the difficulties GPs are facing when using the prescription module, and the testimony given by the GP in this case, it would appear there is no easy system for a doctor to verify exactly what their patient has already been prescribed and whether or not that prescription is still current. Further, in relation to the potential misuse of drugs incorrectly or over-prescribed the GP explained that some medications, such as opioids or anti depression medication (including amitriptyline and sertraline) had ‘currency’ within the prison and it was known they would be traded by some prisoners. Therefore, not being able to readily identify what a prisoner should be, or already is being prescribed at the time of any specific consultation is again clearly a cause for concern. In an interview the GP had with investigators from the Prisons and Probation Ombudsman’s Office on the 30th December 2015 (just one day after Mark’s death) the GP described the prescription module as “an absolute nightmare and we are banging our heads against a brick wall. We’re trying hard to get some changes done because we are concerned about safety” When specifically questioned at the inquest on the 3rd September 2019 the GP stated that the situation as it stood at the end of December 2015 had still not been resolved. ”
    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