West Quay Medical Centre

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First report 18 Dec 2018•Latest report 18 Dec 2018

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
2

Described in responses

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.

  1. Addressed to “West Quay Surgery”, a former name of West Quay Medical Centre.

    South Wales Central

    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
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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