Report evidence summary
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to document and justify the volume of tramadol prescribed despite recorded non-compliance and self-medication
Wider context from the report “4. There was a recorded history of non-compliance and deliberate self-medication of painkillers by Mrs Elliott. Despite that a GP immediately before her death in a telephone consultation prescribed her with 100 tramadol tablets whilst recording that she needed an urgent review. The rationale for prescribing this volume of medication was unclear from the notes ;
” Is this part of a recurring concern? Yes — Unsafe medication prescribing .
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure of the GP practice recording system to accurately distinguish repeat and acute prescriptions
Wider context from the report “1. The GP practice computer recording system showed drugs that were clearly on repeat prescription as drugs that were acute prescriptions. As a result the inquest was told that the medication reviews carried out would not pick up on and would not review those prescriptions. The medication reviewer would not therefore have a full overview of her prescribed long term medication;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to explore alternatives to repeated painkiller prescribing for persistent back pain
Wider context from the report “5. There was a lack of continuity of care. Mrs Elliott saw a variety of different locum GPs. This meant that no clinician had an overview of her and her health. As a result, painkillers were repeatedly prescribed and other potential ways of managing her persistent back pain were not explored . This led to a significant reliance by Mrs Elliott on painkillers to manage her on going back problems. The inquest was told that the lack of continuity of care was due to a national shortage of GPs and was a national not local issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of continuity of care preventing a clinician from maintaining an overview of the patient and her health
Wider context from the report “5. There was a lack of continuity of care. Mrs Elliott saw a variety of different locum GPs. This meant that no clinician had an overview of her and her health. As a result, painkillers were repeatedly prescribed and other potential ways of managing her persistent back pain were not explored. This led to a significant reliance by Mrs Elliott on painkillers to manage her on going back problems. The inquest was told that the lack of continuity of care was due to a national shortage of GPs and was a national not local issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of detail in GP and ANP consultation notes
Wider context from the report “2. The notes made by GPs and the ANP who had seen her/had telephone consultations lacked detail and so it was difficult to assess what information had been provided previously and what advice she had been given ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to document the extent and issues considered during medication reviews
Wider context from the report “3. There was no detail provided in the notes at the inquest of the extent or issues considered during the medication reviews that were recorded as having taken place ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Medication reviews failing to provide a full overview of prescribed long-term medication
Wider context from the report “1. The GP practice computer recording system showed drugs that were clearly on repeat prescription as drugs that were acute prescriptions. As a result the inquest was told that the medication reviews carried out would not pick up on and would not review those prescriptions . The medication reviewer would not therefore have a full overview of her prescribed long term medication ;
” 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 Hold regular clinical meetings with the practice to maintain and monitor an action plan.
Verbatim wording from the response “The CCG is working very closely with the practice including:” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Review CCG governance for identifying practices needing support with robust clinical services.
Verbatim wording from the response “The CCG is working very closely with the practice including:” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Deliver a comprehensive safeguarding training programme for all practice staff.
Verbatim wording from the response “The CCG is working very closely with the practice including:” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Consider running education sessions on non-pharmacological pain management and referral criteria for musculoskeletal services.
Verbatim wording from the response “Increase awareness of and consider running GP, nurse and pharmacist education sessions regarding non-pharmacological management of pain and criteria for referral to MSK service.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Educate GPs and pharmacists to review acute, repeat and recently issued medicines during medication reviews.
Verbatim wording from the response “Actions agreed with the CCG and in progress” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Review clinical staffing numbers and clinical sessions to support patient continuity and existing staff.
Verbatim wording from the response “The CCG is working very closely with the practice including:” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Liaise with EMIS to request medication-review fields and prompts, while assessing current functionality to improve recording.
Verbatim wording from the response “2. In the EMIS system a medication review is usually recorded by clicking on the medication review date at the bottom of the medication screen. This only allows recording of the read code for medication review and has no facility for recording the details of the review. The only way to record details of the review is to open” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Summarize medication-related incidents and require the practice to follow up and report actions to the CCG.
Verbatim wording from the response “The CCG is working very closely with the practice including:” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Provide GPs and non-medical prescribers with tools, information and education on safer prescribing and medication review.
Verbatim wording from the response “As a CCG we will offer advice to all GPs and Non-Medical Prescribers around these actions, this will be in the role of an enabler by providing appropriate tools and information/education. Our Medicines Optimisations team will continue to support practices to achieve and maintain the changes through an ongoing system of audit, against the Gold Standard Repeat Prescribing guidelines and medication review.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Document follow-up plans and dosage advice whenever medication is started.
Verbatim wording from the response “Actions agreed with the CCG and in progress” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Ask patients during medication reviews about medicines obtained outside the GP practice, including hospital, relative-supplied and over-the-counter medicines.
Verbatim wording from the response “When undertaking a medication review ensure patients are asked whether they are taking medication that has not been prescribed to them by the GP – including whether they are taking any hospital prescribed medication, a relative’s medication or OTC medicines. It is not clear where this patient obtained amitriptyline from but if this question had been asked it may have been identified.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Add patient alerts for concerns about overuse of painkillers or other medicines.
Verbatim wording from the response “Actions agreed with the CCG and in progress” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Share learning from the practice improvement plan with all Trafford practices to improve prescribing and repeat prescribing.
Verbatim wording from the response “The learning that the CCG has gained in working with Delamere practice on their improvement plan will be shared with all practices across Trafford to highlight the risks that have been identified in this case. This should also improve the quality of prescribing and repeat prescribing across all Trafford GP practices. Currently we are not aware of any other GP practices with the same level of risk. However to mitigate any potential risk we have now included the risks of repeat prescribing within our level three safeguarding training this commenced on 7th March 2019.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Provide and document advice on non-pharmacological treatments when prescribing analgesia.
Verbatim wording from the response “Actions agreed with the CCG and in progress” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Reset medication review dates for follow-up when requested blood tests remain outstanding.
Verbatim wording from the response “4. When undertaking a review – if blood tests have been requested but the patient had not yet attended, the medication review date should be re-set for a short period so that if the patient does not attend for blood tests this is followed up.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Share learning on medication follow-up, dosage advice and non-pharmacological pain treatment with GPs through training and newsletters.
Verbatim wording from the response “1. When medication is started document the plan for follow-up/review and any advice given relating to the dose to take.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Audit practices against repeat-prescribing and medication-review standards to support and maintain safety improvements.
Verbatim wording from the response “As a CCG we will offer advice to all GPs and Non-Medical Prescribers around these actions, this will be in the role of an enabler by providing appropriate tools and information/education. Our Medicines Optimisations team will continue to support practices to achieve and maintain the changes through an ongoing system of audit, against the Gold Standard Repeat Prescribing guidelines and medication review.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 documentation of reasons and review plans when regular long-term medicines are issued acutely.
Verbatim wording from the response “2. If regular long-term medications are issued as acute – document the reason for this and the plan for review so that when they are issued other prescribers are aware of the plan. Otherwise there is a danger that acute items will be issued long-term without a review, with the person issuing assuming that because it is on acute someone else will review it next time.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 medication reviews to record the medicines and content reviewed, with follow-up appointments when reviews are incomplete.
Verbatim wording from the response “The medication review date is primarily set to ensure that repeat medication gets reviewed at regular intervals. As previously stated this should also include a review of any medication on the acute list. A medication review may be a review of the medical notes or a review with the patient in a telephone consultation or face to face.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Make prescribers aware that EMIS can set review dates for individual medicines.
Verbatim wording from the response “For individual medicines that require an earlier review prescribers should be made aware of the facility to set a review date for that individual medicine (rather than authorisations which are less specific and can be overridden)” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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 Review prescribing and other quality markers to identify practice improvement needs.
Verbatim wording from the response “The CCG is working very closely with the practice including:” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The EMIS Web system distinguishes acute and repeat medicines and supports comprehensive medication reviews, so medicines need not be placed on repeat lists.
Verbatim wording from the response “I am advised that on the matter of the GP practice computer system and the recording of prescriptions, it could be that certain medications were not added to the repeat list to avoid them being issued without review. For example, if a medication is on the acute medication list then an active decision has to be made to re-issue the prescription. This would require a doctor to look at when the medication was last issued, and to review the indication for the drug to ensure the need for it was still evident.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Detailed consultation records are the responsibility of individual clinicians rather than a limitation of the GP computer system.
Verbatim wording from the response “It is important to note that full and accurate record keeping is the responsibility of the clinician. A lack of detailed records of consultations is related to the quality of record keeping by individual GPs and not to the GP clinical computer system capability.” Source location 2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
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