Your Health Partnership – Regis Medical Centre

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First report 27 Oct 2025•Latest report 27 Oct 2025

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
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Your Health Partnership – Regis Medical Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Black Country

    AI-generated summary

    Danielle Monique Christina JONES · 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

    Danielle Jones was found unresponsive at home on 13 May 2025 and was confirmed deceased by paramedics. Post-mortem toxicology found high levels of amitriptyline, excess zopiclone and recent substantial cocaine use; the recorded cause was combined multidrug toxicity. The principal concerns were that, despite reported prescription overdoses and concerns raised by a drug and alcohol service, her repeat prescription medication does not appear to have been reviewed and was continued in large quantities at 28-day frequency.

    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 Your Health Partnership – Regis Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record clinical rationale for continued repeat prescribing in light of overdose risk

    Wider context from the report

    “5. Although Miss Jones was signposted to Mental Health Services by her GP, her prescription medications do not appear to have been reviewed and the GP surgery continued to prescribed repeat medications in large amounts at 28 day frequency without any further review subsequent to her appointment on 25/2/25. 6. She was issued with repeat prescriptions on 3 occasions subsequent to her appointment on 24th and 25th February 2025 when she self-closed an overdose of prescription medication. 7. On 6/3/25 despite a recent self-reported admitted overdose of prescription medication of ████████ ████████ ████████ Miss Jones was prescribed 8. On 27/3/25 despite a recent self-reported admitted overdose of prescription medication of ████████ ████████ Miss Jones was prescribed Amitriptyline ████████ Diazepam ████████ lamotrigine ████████ mirtazapine ████████ pregabalin ████████ zopiclone 9. On 28/4/25 despite a recent self-reported admitted overdose of prescription medication of ████████ ████████████████████████████████████████ Miss Jones was prescribed ████████ ████████████████████████████████████████████████████████████████████████ ████████████████████████████████████████████████████████████████████████ 10. Miss Jones died on 13/5/25 from the combined toxic effects of a fatal level of amitriptyline along with an excessive amount of zopiclone. 11. The clinical lead at Cranstoun had previously had discussions with the GP about reducing Miss Jones prescription for zopiclone. 12. No medication review appears to have taken place after Miss Jones self-reported overdose of prescribed medication nor after concerns were raised by Cranstoun. 13. GMC Guidance requires a practitioner to prescribe drugs or treatment including repeat prescriptions, only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs and to keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made. 14. There is no clinical rationale recorded for the continued prescribing of Miss Jones’s repeat medications in terms of managing Miss Jones’s risk of overdose given her recent disclosure e.g. reducing the frequency to 7 days rather than 28 days. 15. There is no evidence of any medication review having taken place after Miss Jones’s disclosure of overdose of prescription medication or prior to her repeat prescriptions being issued on 6/2/25, 27/3/25 or 28/4/25. Her last reported medication review was on 23/8/24. ”
    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 Your Health Partnership – Regis Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Continued prescribing of repeat medications in large amounts at 28-day frequency after overdose disclosure

    Wider context from the report

    “5. Although Miss Jones was signposted to Mental Health Services by her GP, her prescription medications do not appear to have been reviewed and the GP surgery continued to prescribed repeat medications in large amounts at 28 day frequency without any further review subsequent to her appointment on 25/2/25. 6. She was issued with repeat prescriptions on 3 occasions subsequent to her appointment on 24th and 25th February 2025 when she self-closed an overdose of prescription medication. 7. On 6/3/25 despite a recent self-reported admitted overdose of prescription medication of ████████ ████████ ████████ Miss Jones was prescribed 8. On 27/3/25 despite a recent self-reported admitted overdose of prescription medication of ████████ ████████ Miss Jones was prescribed Amitriptyline ████████ Diazepam ████████ lamotrigine ████████ mirtazapine ████████ pregabalin ████████ zopiclone 9. On 28/4/25 despite a recent self-reported admitted overdose of prescription medication of ████████ ████████████████████████████████████████ Miss Jones was prescribed ████████ ████████████████████████████████████████████████████████████████████████ ████████████████████████████████████████████████████████████████████████ 10. Miss Jones died on 13/5/25 from the combined toxic effects of a fatal level of amitriptyline along with an excessive amount of zopiclone. 11. The clinical lead at Cranstoun had previously had discussions with the GP about reducing Miss Jones prescription for zopiclone. 12. No medication review appears to have taken place after Miss Jones self-reported overdose of prescribed medication nor after concerns were raised by Cranstoun. 13. GMC Guidance requires a practitioner to prescribe drugs or treatment including repeat prescriptions, only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs and to keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made. 14. There is no clinical rationale recorded for the continued prescribing of Miss Jones’s repeat medications in terms of managing Miss Jones’s risk of overdose given her recent disclosure e.g. reducing the frequency to 7 days rather than 28 days. 15. There is no evidence of any medication review having taken place after Miss Jones’s disclosure of overdose of prescription medication or prior to her repeat prescriptions being issued on 6/2/25, 27/3/25 or 28/4/25. Her last reported medication review was on 23/8/24. ”
    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 Your Health Partnership – Regis Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct medication reviews after overdose disclosures and related concerns

    Wider context from the report

    “5. Although Miss Jones was signposted to Mental Health Services by her GP, her prescription medications do not appear to have been reviewed and the GP surgery continued to prescribed repeat medications in large amounts at 28 day frequency without any further review subsequent to her appointment on 25/2/25. 6. She was issued with repeat prescriptions on 3 occasions subsequent to her appointment on 24th and 25th February 2025 when she self-closed an overdose of prescription medication. 7. On 6/3/25 despite a recent self-reported admitted overdose of prescription medication of ████████ ████████ ████████ Miss Jones was prescribed 8. On 27/3/25 despite a recent self-reported admitted overdose of prescription medication of ████████ ████████ Miss Jones was prescribed Amitriptyline ████████ Diazepam ████████ lamotrigine ████████ mirtazapine ████████ pregabalin ████████ zopiclone 9. On 28/4/25 despite a recent self-reported admitted overdose of prescription medication of ████████ ████████████████████████████████████████ Miss Jones was prescribed ████████ ████████████████████████████████████████████████████████████████████████ ████████████████████████████████████████████████████████████████████████ 10. Miss Jones died on 13/5/25 from the combined toxic effects of a fatal level of amitriptyline along with an excessive amount of zopiclone. 11. The clinical lead at Cranstoun had previously had discussions with the GP about reducing Miss Jones prescription for zopiclone. 12. No medication review appears to have taken place after Miss Jones self-reported overdose of prescribed medication nor after concerns were raised by Cranstoun. 13. GMC Guidance requires a practitioner to prescribe drugs or treatment including repeat prescriptions, only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs and to keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made. 14. There is no clinical rationale recorded for the continued prescribing of Miss Jones’s repeat medications in terms of managing Miss Jones’s risk of overdose given her recent disclosure e.g. reducing the frequency to 7 days rather than 28 days. 15. There is no evidence of any medication review having taken place after Miss Jones’s disclosure of overdose of prescription medication or prior to her repeat prescriptions being issued on 6/2/25, 27/3/25 or 28/4/25. Her last reported medication review was on 23/8/24. ”
    Open source report
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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