6 Jun 2017 Mr George Arthur Cheese · Prevention of Future Deaths report Berkshire
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Concerns raised 2 Failure to flag suicidal thoughts and potential overdose risk in patient notes View source Failure to limit the amount of antidepressant medication prescribed to patients with suicidal thoughts View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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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.
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× 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
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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
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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
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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
Open published response
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations