Recipient

Waterside Medical Centre

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First report 12 May 2014•Latest report 12 May 2014

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Social-care 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
100%

Found for named reports

Concerns addressed
1

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.

100%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Waterside Medical Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Portsmouth and South East Hampshire

    AI-generated summary

    Courtney Jordan Mills · 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

    Courtney Jordan Mills was found unresponsive in bed at home on 19 April 2013 and was pronounced deceased at hospital that morning. The concerns included repeated prescription and communication problems affecting access to Clonodine, which was reported as a medication that should not be stopped abruptly, and the potential risk to other children in similar circumstances. The inquest recorded acute bronchopneumonia in a child with sleep apnoea and cerebral palsy, with death due to natural causes.

    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 Waterside Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to issue correct Clonodine prescriptions

    Wider context from the report

    “I was told that (quote): "Courtney was on a quantity of different medication for her conditions one of which is "Clonodine". Her parents reported that they had been having problems getting the correct prescriptions for this from the GP surgery (written as tablets instead of solution, wrong dosage etc) and this caused problems. This drug cannot just be stopped as the patient suffers from withdrawal symptoms and has to be weaned off gradually. The drug was ordered in by the Pharmacist and could take 5 days to get in so the prescription was always requested in advance of when it was required. Courtney's supply was running low and a prescription was collected by mother and taken to the pharmacy. She returned a few days later she was told that the prescription had been written wrongly and had been returned to the GP and she should have been called by them. Neither parent had received a call. Mother attended the surgery and was told that the prescription could not be done until they had spoken to Courtney's consultant at SGH, ████████ and they would be called when done. No calls received. Courtney's last dose of this medication was due to be given on Thursday morning and father continued to contact the GP surgery on Wednesday but was told it was not ready, he called again on Thursday to an answering machine stating the practice was closed for a training day. He was due to go into the surgery this morning to discuss the matter with the GPs." I was also told that Clonodine could be obtained from the pharmacy at Queen Alexandra Hospital for patients under the care of a consultant - as was Courtney. There had been a history of delay in her obtaining this medication due to communication difficulties between the hospital and her GP surgery. I believe such a problem could put other children's lives at risk in similar circumstances. ”
    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 Waterside Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate and coordinate timely Clonodine supply

    Wider context from the report

    “I was told that (quote): "Courtney was on a quantity of different medication for her conditions one of which is "Clonodine". Her parents reported that they had been having problems getting the correct prescriptions for this from the GP surgery (written as tablets instead of solution, wrong dosage etc) and this caused problems. This drug cannot just be stopped as the patient suffers from withdrawal symptoms and has to be weaned off gradually. The drug was ordered in by the Pharmacist and could take 5 days to get in so the prescription was always requested in advance of when it was required. Courtney's supply was running low and a prescription was collected by mother and taken to the pharmacy. She returned a few days later she was told that the prescription had been written wrongly and had been returned to the GP and she should have been called by them. Neither parent had received a call. Mother attended the surgery and was told that the prescription could not be done until they had spoken to Courtney's consultant at SGH, ████████ and they would be called when done. No calls received. Courtney's last dose of this medication was due to be given on Thursday morning and father continued to contact the GP surgery on Wednesday but was told it was not ready, he called again on Thursday to an answering machine stating the practice was closed for a training day. He was due to go into the surgery this morning to discuss the matter with the GPs." I was also told that Clonodine could be obtained from the pharmacy at Queen Alexandra Hospital for patients under the care of a consultant - as was Courtney. There had been a history of delay in her obtaining this medication due to communication difficulties between the hospital and her GP surgery. I believe such a problem could put other children's lives at risk in similar circumstances. ”
    Open source report

    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 delay obtaining Clonidine solution was due to community supply constraints, not communication difficulties between the surgery and hospital.

    Verbatim wording from the response

    “████████ then spoke to ████████ on the telephone on 18.04.2013 regarding the Clonidine prescription. They discussed the transdermal option but ████████ felt there were medico-legal issues as it was off licence. ████████ felt that it was more appropriate that Southampton carried on supplying the medication and explained the difficulties to ████████ these being that there was a week’s delay, minimum, in sourcing Clonidine solution in the community and it was also impossible to issue it via the computer.”

    Source location

    2014-0224-Response-by-Waterside-Medical-Centre
    Page 2 · response
    Published 12 May 2014

    Open published response

    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

    Southampton Hospital should continue supplying Clonidine solution because community pharmacies could not readily obtain it.

    Verbatim wording from the response

    “████████ then spoke to ████████ on the telephone on 18.04.2013 regarding the Clonidine prescription. They discussed the transdermal option but ████████ felt there were medico-legal issues as it was off licence. ████████ felt that it was more appropriate that Southampton carried on supplying the medication and explained the difficulties to ████████ these being that there was a week’s delay, minimum, in sourcing Clonidine solution in the community and it was also impossible to issue it via the computer.”

    Source location

    2014-0224-Response-by-Waterside-Medical-Centre
    Page 2 · response
    Published 12 May 2014

    Open published response
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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

100%
100%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