Concerns raised 5 Prescribing of amitriptyline above the maximum suggested dose for a patient known to be dependent on it View source Failure to maintain daily amitriptyline dispensing to mitigate overdose risk View source Failure to flag the overdose risk and stop continued amitriptyline prescribing View source Failure to record acknowledged amitriptyline risks in an accessible way for all practitioners View source Prescribing of amitriptyline for depression despite its increased risk of fatality in overdose View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Tracy Frances MCCARTHY · 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
Tracy McCarthy was found deceased at home on 17 July 2023 and died from long-term misuse of amitriptyline; the inquest conclusion was a drug-related death, with amitriptyline toxicity and coronary artery disease recorded. The concerns included prescribing amitriptyline above the maximum suggested dose, failure to flag the overdose risk and stop or appropriately manage the prescription, and changing from daily to monthly prescriptions despite recognised risks.
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 Tredegar Practice; that does not assign responsibility.
PFD Monitor interpretation Prescribing of amitriptyline above the maximum suggested dose for a patient known to be dependent on it
Wider context from the report “(1) Although Amitriptyline is not generally regarded as a drug of abuse, Ms McCarthy was known to be dependent on it . She had been prescribed Amitriptyline for many years, and at one stage in or about 2022, she was regularly prescribed ████████ mg per day, which is over the maximum suggested dose in the BNF (150mg per day) . In addition, the BNF provides a clear warning (as did the prescribing/records software in use at The Tredegar Practice) that Amitriptyline prescribed for depression (which it was in this case), is “not recommended – increased risk of fatality in overdose”. A GP from The Tredegar Practice told me that ████████ mg was an “unacceptable dose” .
The concern being that guidelines were not followed, particularly in relation to a patient known to be dependent and where use of Amitriptyline was not recommended for the presenting condition in any event.
” 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 Tredegar Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain daily amitriptyline dispensing to mitigate overdose risk
Wider context from the report “(3) Ms McCarthy’s Amitriptyline prescriptions had previously been issued on a daily basis, to mitigate the risk of overdose . However, following her admission to hospital (mentioned above) a GP at The Tredegar Practice took the decision to reduce the dose slightly, but transfer to monthly prescriptions, thereby allowing Ms McCarthy access to 28 days’ worth of Amitriptyline all at once . A GP from The Tredegar Practice told me that they thought this was “risky” but said that the GP who made that decision was not familiar with the patient and maybe wouldn’t have known the rationale for daily prescriptions. They also told me that the Practice was probably “over-reliant on the knowledge of particular doctors that treated her.”
The concern is that too great an emphasis was placed on the knowledge of a few individuals, which led to acknowledged risks not being put in the records in a way that would alert any practitioner to them.
” 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 Tredegar Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to flag the overdose risk and stop continued amitriptyline prescribing
Wider context from the report “(2) Following Ms McCarthy’s admission to hospital as a result of an overdose of Amitriptyline and Codeine, The Tredegar Practice received information from the hospital, making reference to the overdose. Despite this, the risk was not flagged and no alert was put on the system ; as such, the prescription of Amitriptyline continued . A GP from The Tredegar Practice told me, “[the Amitriptyline] should have been stopped, but knowing [the patient] that would have been very hard to do.”
” 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 Tredegar Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to record acknowledged amitriptyline risks in an accessible way for all practitioners
Wider context from the report “(3) Ms McCarthy’s Amitriptyline prescriptions had previously been issued on a daily basis, to mitigate the risk of overdose. However, following her admission to hospital (mentioned above) a GP at The Tredegar Practice took the decision to reduce the dose slightly, but transfer to monthly prescriptions, thereby allowing Ms McCarthy access to 28 days’ worth of Amitriptyline all at once. A GP from The Tredegar Practice told me that they thought this was “risky” but said that the GP who made that decision was not familiar with the patient and maybe wouldn’t have known the rationale for daily prescriptions. They also told me that the Practice was probably “over-reliant on the knowledge of particular doctors that treated her.”
The concern is that too great an emphasis was placed on the knowledge of a few individuals , which led to acknowledged risks not being put in the records in a way that would alert any practitioner to them .
” 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 Tredegar Practice; that does not assign responsibility.
PFD Monitor interpretation Prescribing of amitriptyline for depression despite its increased risk of fatality in overdose
Wider context from the report “(1) Although Amitriptyline is not generally regarded as a drug of abuse, Ms McCarthy was known to be dependent on it. She had been prescribed Amitriptyline for many years, and at one stage in or about 2022, she was regularly prescribed ████████ mg per day, which is over the maximum suggested dose in the BNF (150mg per day). In addition, the BNF provides a clear warning (as did the prescribing/records software in use at The Tredegar Practice) that Amitriptyline prescribed for depression (which it was in this case), is “not recommended – increased risk of fatality in overdose” . A GP from The Tredegar Practice told me that ████████ mg was an “unacceptable dose”.
The concern being that guidelines were not followed, particularly in relation to a patient known to be dependent and where use of Amitriptyline was not recommended for the presenting condition in any event .
” 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 Conduct regular reviews of registered patients and the overall framework, documenting, minuting, and circulating review outcomes.
Verbatim wording from the response “4. Reviews: regular reviews will be needed in the process.” Source location Response from The GP Partners
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 Identify eligible complex patients, add them to the Risk Management & Care Planning Register, and create corresponding care plans and EMIS alerts.
Verbatim wording from the response “2. Identification of patients to be entered into the framework.” Source location Response from The GP Partners
Open published response
17 Oct 2014 Stephen Atherton · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Delays in radiologist-recommended additional investigations when GPs cannot request them View source Lack of a system at the GP practice to ensure successful receipt of important correspondence View source Failure to clinically triage routine orthopaedic referrals View source Lack of appropriate safeguards to prevent patients at risk from leaving before capacity assessment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Stephen Atherton · 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 Atherton, aged 27, died on 16 May 2013 from severe head injuries after falling from height after leaving a neurosurgical ward. The report identified concerns about delays and communication in referrals and investigations, and about the absence of safeguards to prevent him leaving the ward despite risks to himself.
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 Tredegar Practice; that does not assign responsibility.
PFD Monitor interpretation Delays in radiologist-recommended additional investigations when GPs cannot request them
Wider context from the report “(3) Mr Atherton required multiple investigations of increasing complexity, at the recommendation of the reporting radiologists. I heard compelling evidence from Mr Atherton’s GP that this process results in delays . This is because the investigations could be undertaken more quickly if the radiologists themselves instigated the necessary additional investigations . This is particularly the case where the suggested investigations cannot actually be requested by GPs . The Trust gave evidence that this process is necessary because of the commissioning arrangements in place, which determine how payment is made for such tests. I am concerned that this process could increase the risk of future deaths occurring in similar circumstances to Mr Atherton’s case.
” 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 Tredegar Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of a system at the GP practice to ensure successful receipt of important correspondence
Wider context from the report “(1) It was clear from the evidence at the inquest that Mr Atherton’s GP was concerned that he should be seen for orthopaedic review more quickly than had been planned. However, was concerned that, given the importance of this further correspondence, there was no system in place at the GP practice to ensure successful receipt of the fax .
” 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 Tredegar Practice; that does not assign responsibility.
PFD Monitor interpretation Failure to clinically triage routine orthopaedic referrals
Wider context from the report “(2) I heard evidence that routine ‘choose and book’ orthopaedic referrals are not clinically triaged by the specialist to whom the referrals are made . As such, the concern was raised (which I share) that there is no potential for the triaging of apparently ‘routine’ appointments which, with specialist input might be expedited . It was clear from the evidence heard that other departments routinely triage referrals and no evidence was provided as to why this is not undertaken by the orthopaedic department.
” 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 Tredegar Practice; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate safeguards to prevent patients at risk from leaving before capacity assessment
Wider context from the report “(4) The neurosurgical ward from which Mr Atherton self-discharged was not locked. This was despite the risk he posed to himself and the fact that the staff were clear he should not be free to leave, without medical assessment of his capacity to self-discharge . I heard evidence that the current legislative framework and case law means that locking of wards is not acceptable. Whilst it is clear that locking ward doors by default is not appropriate, I did not hear compelling evidence as to why mechanisms could not be put in place to facilitate temporary locking . I am concerned that the legal position is being interpreted so that no appropriate safeguards exist , which would have prevented Mr Atherton from absconding. This raises concerns that future deaths could result in such circumstances, if this issue is not addressed.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations