Concerns raised 4 Lack of a system for obtaining and recording illicit drug misuse information to support informed prescribing risk assessment and review View source Failure to enquire about patients’ current or continued illicit drug misuse View source Failure to record enquiries about illicit drug misuse and patients’ responses View source Risk of respiratory depression from concomitant pregabalin and oxycodone use in patients with compromised respiratory systems View source See 1 more concern
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. 3
Action
Search the clinical system regularly for patients receiving regular opiate analgesia or Pregabalin who have a history of drug misuse.
View source
Action
Discuss illicit-drug-use recording requirements and clarify that stopped intravenous drug use does not establish cessation of all illicit drug use.
View source
Action
Contact identified patients to update records of their current illicit drug use.
View source
×
AI-generated summary
Deborah Chapman · 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
Deborah Chapman, who had COPD, chronic pain, and continued to misuse heroin and crack cocaine, was found unresponsive at home on 3 March 2019 and was pronounced dead at 7.06am. The post-mortem attributed her death to the combined toxic effects of heroin, oxycodone and pregabalin, together with COPD. Concerns included whether her ongoing illicit drug use and the risks of combining prescribed and illicit drugs had been adequately assessed and recorded when prescribing oxycodone and pregabalin.
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 Timperley Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for obtaining and recording illicit drug misuse information to support informed prescribing risk assessment and review
Wider context from the report “5. Furthermore, the evidence did not reveal any system in place at the West Timperley Medical Centre to ensure that the information about illicit drug misuse is obtained and recorded from patients in order to ensure that an informed assessment of the risks of the concomitant use prescribed and illicit drugs could be made and reviewed .
” 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 Timperley Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to enquire about patients’ current or continued illicit drug misuse
Wider context from the report “2. The evidence I heard from the records held at the medical centre did not reveal the extent to which any enquiry was made of Ms Chapman as to her current misuse of illicit drugs either on the occasion of her re-joining the medical practice as a patient in July 2018 or at subsequent consultations. There were clear signs of a dependence on the prescribed opiate drugs and the medical records equally revealed long-term illicit opiate misuse.
3. The evidence I heard from the medical records held at the medical centre did not reveal, beyond the admitted dependence on the prescribed medication, what enquiry had been made from Ms Chapman in relation to her continued misuse of illicit drugs or her response to those enquiries.
4. In the absence of that information, it was not possible, from the medical records, to ascertain what level of risk the continued illicit misuse of opiates posed to Ms Chapman and therefore, whether, on an informed basis, pregabalin and oxycodone were appropriate prescriptions.
” 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 Timperley Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to record enquiries about illicit drug misuse and patients’ responses
Wider context from the report “2. The evidence I heard from the records held at the medical centre did not reveal the extent to which any enquiry was made of Ms Chapman as to her current misuse of illicit drugs either on the occasion of her re-joining the medical practice as a patient in July 2018 or at subsequent consultations. There were clear signs of a dependence on the prescribed opiate drugs and the medical records equally revealed long-term illicit opiate misuse.
3. The evidence I heard from the medical records held at the medical centre did not reveal , beyond the admitted dependence on the prescribed medication, what enquiry had been made from Ms Chapman in relation to her continued misuse of illicit drugs or her response to those enquiries.
4. In the absence of that information, it was not possible, from the medical records, to ascertain what level of risk the continued illicit misuse of opiates posed to Ms Chapman and therefore, whether, on an informed basis, pregabalin and oxycodone were appropriate prescriptions.
” 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 Timperley Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Risk of respiratory depression from concomitant pregabalin and oxycodone use in patients with compromised respiratory systems
Wider context from the report “1. I heard evidence from ████████ representing the West Timperley Medical Centre. He acknowledged that the known side effects of both pregabalin and oxycodone, both individually and concomitantly, presented a risk of having a depressive effect on the respiratory system . He also acknowledged that Ms Chapman’s COPD represented an underlying compromise of her respiratory system .
” 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 Search the clinical system regularly for patients receiving regular opiate analgesia or Pregabalin who have a history of drug misuse.
Verbatim wording from the response “We have put in place a regular search of our clinical system to identify patients that are taking regular opiate analgesia and who have a past history of drug misuse. A similar search has been undertaken for those patients taking regular Pregabalin. The searches have identified 16 patients taking regular opiate analgesia with a history of drug misuse and 7 patients taking Pregabalin with a history of past drug misuse. We are currently contacting those patients to ensure that we have an up to date record of their current illicit drug use.” Source location 2019-0280-Response-from-West-Timperley-Medical-Centre-Redacted
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 Discuss illicit-drug-use recording requirements and clarify that stopped intravenous drug use does not establish cessation of all illicit drug use.
Verbatim wording from the response “In the first instance, Mrs Chapman’s death was discussed in a Primary Care Team Meeting. In particular, the need to ensure we have an up to date record of all illicit drug use was emphasised and a reminder of the fact that a record of intravenous drug abuse having been stopped does not mean that all illicit drug use has been stopped.” Source location 2019-0280-Response-from-West-Timperley-Medical-Centre-Redacted
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 Contact identified patients to update records of their current illicit drug use.
Verbatim wording from the response “We have put in place a regular search of our clinical system to identify patients that are taking regular opiate analgesia and who have a past history of drug misuse. A similar search has been undertaken for those patients taking regular Pregabalin. The searches have identified 16 patients taking regular opiate analgesia with a history of drug misuse and 7 patients taking Pregabalin with a history of past drug misuse. We are currently contacting those patients to ensure that we have an up to date record of their current illicit drug use.” Source location 2019-0280-Response-from-West-Timperley-Medical-Centre-Redacted
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations