Recipient

West Quay Medical Centre

First report 18 Dec 2018•Latest report 18 Dec 2018

Recipient record

Reports, concerns and published responses

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

Reports: 1
Published responses: 100%
Concerns addressed: 2
Stated actions: 2

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

2stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

18 Dec2018
South Wales Central
Concerns raised5
1. Failure to communicate accurate overdose information to liaison psychiatry
2. Failure to arrange psychiatric liaison assessment and professional follow-up after overdose
3. Inadequate risk history-taking during clinical consultation
1. Failure to perform suitably frequent medication reviews
2. Availability of many boxes of different repeat-prescribed tablets posing an overdose risk
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Discuss the report’s medication-review and high-risk-patient learning at the monthly significant-events meeting with clinical staff.
  Stated planned
2. Action
  Employ a full-time clinical pharmacist to oversee and improve prescribing governance and patient monitoring.
  Stated completed
AI-generated summary

Mrs Ruth Ellen Edwards · 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

Mrs Ruth Ellen Edwards died at home on 31 August 2018 after hanging herself from an attic ladder, following a long history of mental health problems and previous suicide attempts. Concerns included her discharge after a drug overdose without psychiatric liaison assessment, inadequate risk assessment and inaccurate communication about the overdose, and potentially insufficient medication reviews despite access to many medications at home.

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 West Quay Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate accurate overdose information to liaison psychiatry
Wider context from the report
“(2) The consultation at the UHW on 23rd August was poor. The history-taking was inadequate, as it did not reveal the true extent of Mrs Edwards’ risk in terms of previous suicide attempts and deep-seated mental health problems. Furthermore, inaccurate information was communicated to liaison psychiatry: they were told that Mrs Edwards had taken 2 tablets, when she had taken 20. ”
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 West Quay Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to arrange psychiatric liaison assessment and professional follow-up after overdose
Wider context from the report
“(1) Mrs Edwards’ discharge from hospital following overdose on 23rd August to see GP was surprising. It was expected in these circumstances that Mrs Edwards would have been transferred to Llandough Hospital for a psychiatric liaison assessment. Instead, responsibility for any further assessment and treatment of Mrs Edwards was passed entirely to Mrs Edwards and her family. A less capable family/individual may not have pursued help and fallen through the cracks. Furthermore, had Mrs Edwards been hospitalised, her treatment may have been different. ”
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 West Quay Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Inadequate risk history-taking during clinical consultation
Wider context from the report
“(2) The consultation at the UHW on 23rd August was poor. The history-taking was inadequate, as it did not reveal the true extent of Mrs Edwards’ risk in terms of previous suicide attempts and deep-seated mental health problems. Furthermore, inaccurate information was communicated to liaison psychiatry: they were told that Mrs Edwards had taken 2 tablets, when she had taken 20. ”
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 West Quay Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to perform suitably frequent medication reviews
Wider context from the report
“(3) The GP practice may not have performed suitably frequent medication reviews with Mrs Edwards. Many boxes of different tablets were found at the family home, many on repeat prescription, posing an overdose risk. ”
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 West Quay Medical Centre; that does not assign responsibility.
PFD Monitor interpretation
Availability of many boxes of different repeat-prescribed tablets posing an overdose risk
Wider context from the report
“(3) The GP practice may not have performed suitably frequent medication reviews with Mrs Edwards. Many boxes of different tablets were found at the family home, many on repeat prescription, posing an overdose risk. ”
Open source report
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
Discuss the report’s medication-review and high-risk-patient learning at the monthly significant-events meeting with clinical staff.

Verbatim wording from the response
“That said, we would also bring these comments to our monthly significant events meeting to highlight the importance of medication reviews and high risk patients to all of our clinical staff.”

Source location
2018-0395-Response-by-West-Quay-Centre
Page 1 · response
Published 17 May 2019
Open published response
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 full-time clinical pharmacist to oversee and improve prescribing governance and patient monitoring.

Verbatim wording from the response
“Specifically with relation to the comments regarding medication reviews with ourselves as General Practitioners, we would recognise that this presents a particular challenge to us and safe prescribing of medicine requires a great deal of resource. In the last 12 months we have taken on a Clinical Pharmacist within the Practice Team on a full time basis whose responsibility it has been to oversee and improve the governance regarding repeat prescribing and acute prescribing of medications plus patient monitoring. We have in fact achieved an NHS award for quality improvement in this area and although this may have come too late for Mrs Edwards in order to reduce her risk, I would be confident that we have made great strides over and above that we would expect to meet standards of our General Practice.”

Source location
2018-0395-Response-by-West-Quay-Centre
Page 1 · response
Published 17 May 2019
Open published response

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

Reports, concerns and published responses

Reports over time

Concerns raised5

Failure to communicate accurate overdose information to liaison psychiatry

Failure to arrange psychiatric liaison assessment and professional follow-up after overdose

Inadequate risk history-taking during clinical consultation

Failure to perform suitably frequent medication reviews

Availability of many boxes of different repeat-prescribed tablets posing an overdose risk

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.2

Actions described in response 2