Woodley Centre Surgery

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First report 6 Jun 2017•Latest report 6 Jun 2017

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
6

Described in responses

Concerns and recipient responses

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

  1. Berkshire

    AI-generated summary

    Mr George Arthur Cheese · 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

    Mr George Arthur Cheese, an 18-year-old man, was found hanging in woodland near his home on 9 April 2015. He had anxiety and depression with suicidal thoughts, and concerns were raised about the amount of Fluoxetine prescribed and the absence of a flag to limit repeat medication supplies.

    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 Woodley Centre Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to flag suicidal thoughts and potential overdose risk in patient notes

    Wider context from the report

    “(2) Mr Cheese was prescribed Fluoxetine anti-depressant medication on the 3rd November 2014 by a treating GP, following admitting to fleeting suicidal thoughts. He was reviewed by ████████ on 14th January 2015 when Mr Cheese described daily episodes of intense low mood with suicidal thoughts which included taking an overdose. This led to a reference to the Mental Health Team. At an appointment with the Practice’s Nurse Practitioner on 3rd February, Mr Cheese was prescribed 112 tablets of Fluoxetine. In the course of her evidence, ████████ stated that the Nurse Practitioner was probably just repeating the same prescription that the previous Doctor had issued to Mr Cheese but that she, ████████, would not have done that. (3) ████████ also acknowledged, in the course of her evidence, that there was no “flag” on Mr Cheese’s notes to alert treating Clinicians within the GP Practice to limit the amount of medication provided to Mr Cheese in view of his history. She acknowledged that a flag, in such circumstances, was good practice. (4) The concerns arising from the evidence are therefore the amount of medication prescribed to a patient who was known to be suffering from mental health issues and describing suicidal thoughts and a potential overdose and the fact that this was not being flagged to prevent large amounts of medication being provided to him as a matter of repeat prescription. ”
    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 Woodley Centre Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to limit the amount of antidepressant medication prescribed to patients with suicidal thoughts

    Wider context from the report

    “(2) Mr Cheese was prescribed Fluoxetine anti-depressant medication on the 3rd November 2014 by a treating GP, following admitting to fleeting suicidal thoughts. He was reviewed by ████████ on 14th January 2015 when Mr Cheese described daily episodes of intense low mood with suicidal thoughts which included taking an overdose. This led to a reference to the Mental Health Team. At an appointment with the Practice’s Nurse Practitioner on 3rd February, Mr Cheese was prescribed 112 tablets of Fluoxetine. In the course of her evidence, ████████ stated that the Nurse Practitioner was probably just repeating the same prescription that the previous Doctor had issued to Mr Cheese but that she, ████████, would not have done that. (3) ████████ also acknowledged, in the course of her evidence, that there was no “flag” on Mr Cheese’s notes to alert treating Clinicians within the GP Practice to limit the amount of medication provided to Mr Cheese in view of his history. She acknowledged that a flag, in such circumstances, was good practice. (4) The concerns arising from the evidence are therefore the amount of medication prescribed to a patient who was known to be suffering from mental health issues and describing suicidal thoughts and a potential overdose and the fact that this was not being flagged to prevent large amounts of medication being provided to him as a matter of repeat prescription. ”
    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

    Circulate the antidepressant prescribing policy to GPs and nurses or nurse practitioners.

    Verbatim wording from the response

    “Shortly after George died the partners introduced the requirement for the issue of repeat prescriptions and depression reviews to be conducted by GPs only; receptionists are aware that patients with anxiety and depression cannot be seen by nurse practitioners. This policy has been circulated to all our GPs and nurses/nurse practitioners. The addition of a flag - or ‘major alert’ - on the front screen of the patient’s record is the responsibility of the GP who initially assesses or reviews the patient should they have concerns at any time. This could include receiving a letter from Talking Therapies expressing concern about a patient’s suicidal thoughts.”

    Source location

    2017-0179-Response-by-Woodley-Centre-Surgery
    Page 1 · response
    Published 4 August 2017

    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 the significant event at the next clinical meeting.

    Verbatim wording from the response

    “I have written up the role of the clinicians including the issue of 112 capsules of fluoxetine to George on 2 occasions as a ‘significant event’ and will be discussing this at our next clinical meeting on Thursday 27th July. Analysis of significant events is a requirement of the CQC (Care Quality Commission) inspection to demonstrate that events that have been detrimental to patient care have been identified, discussed and lessons have been learnt with the aim of improving the quality of care. We have also arranged for a consultant psychiatrist from the local mental health team to talk about management of mental health disorders at our clinical meeting scheduled for Wednesday 23rd August.”

    Source location

    2017-0179-Response-by-Woodley-Centre-Surgery
    Page 1 · response
    Published 4 August 2017

    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

    Require the assessing or reviewing GP to add a major alert when concerned about a patient’s risk.

    Verbatim wording from the response

    “Shortly after George died the partners introduced the requirement for the issue of repeat prescriptions and depression reviews to be conducted by GPs only; receptionists are aware that patients with anxiety and depression cannot be seen by nurse practitioners. This policy has been circulated to all our GPs and nurses/nurse practitioners. The addition of a flag - or ‘major alert’ - on the front screen of the patient’s record is the responsibility of the GP who initially assesses or reviews the patient should they have concerns at any time. This could include receiving a letter from Talking Therapies expressing concern about a patient’s suicidal thoughts.”

    Source location

    2017-0179-Response-by-Woodley-Centre-Surgery
    Page 1 · response
    Published 4 August 2017

    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

    Require GPs to conduct repeat-prescription issuance and depression reviews.

    Verbatim wording from the response

    “Shortly after George died the partners introduced the requirement for the issue of repeat prescriptions and depression reviews to be conducted by GPs only; receptionists are aware that patients with anxiety and depression cannot be seen by nurse practitioners. This policy has been circulated to all our GPs and nurses/nurse practitioners. The addition of a flag - or ‘major alert’ - on the front screen of the patient’s record is the responsibility of the GP who initially assesses or reviews the patient should they have concerns at any time. This could include receiving a letter from Talking Therapies expressing concern about a patient’s suicidal thoughts.”

    Source location

    2017-0179-Response-by-Woodley-Centre-Surgery
    Page 1 · response
    Published 4 August 2017

    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