Recipient

West Timperley Medical Centre

First report 1 Aug 2019•Latest report 1 Aug 2019

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: 3
Stated actions: 4

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

4stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

1 Aug2019
Manchester South
Concerns raised4
1. Lack of a system for obtaining and recording illicit drug misuse information to support informed prescribing risk assessment and review
2. Failure to enquire about patients’ current or continued illicit drug misuse
3. Failure to record enquiries about illicit drug misuse and patients’ responses
1. Risk of respiratory depression from concomitant pregabalin and oxycodone use in patients with compromised respiratory systems
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Search the clinical system regularly for patients receiving regular opiate analgesia or Pregabalin who have a history of drug misuse.
  Stated completed
2. Action
  Discuss illicit-drug-use recording requirements and clarify that stopped intravenous drug use does not establish cessation of all illicit drug use.
  Stated completed
3. Action
  Contact identified patients to update records of their current illicit drug use.
  Stated in progress
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
Page 1 · response
Published 18 October 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
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
Page 1 · response
Published 18 October 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
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
Page 1 · response
Published 18 October 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 raised4

Lack of a system for obtaining and recording illicit drug misuse information to support informed prescribing risk assessment and review

Failure to enquire about patients’ current or continued illicit drug misuse

Failure to record enquiries about illicit drug misuse and patients’ responses

Risk of respiratory depression from concomitant pregabalin and oxycodone use in patients with compromised respiratory systems

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

Actions described in response 3