PFD report

Jacqueline Marie Elliott · Prevention of Future Deaths report

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Issued 11 Jan 2019•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
7

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
21

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised7

  1. Failure to document and justify the volume of tramadol prescribed despite recorded non-compliance and self-medication
    Part of recurring concern: Unsafe medication prescribing
  2. Failure of the GP practice recording system to accurately distinguish repeat and acute prescriptions
    Part of recurring concern: Inadequate recording of medication prescribing decisions
  3. Failure to explore alternatives to repeated painkiller prescribing for persistent back pain
    Part of recurring concern: Failure to provide timely and adequate pain reliefPart of recurring concern: Unsafe medication prescribing
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.14

  1. Action

    Consider running education sessions on non-pharmacological pain management and referral criteria for musculoskeletal services.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  2. Action

    Educate GPs and pharmacists to review acute, repeat and recently issued medicines during medication reviews.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
  3. Action

    Review clinical staffing numbers and clinical sessions to support patient continuity and existing staff.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The EMIS Web system distinguishes acute and repeat medicines and supports comprehensive medication reviews, so medicines need not be placed on repeat lists.

    Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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; ”

Is this part of a recurring concern?

Yes — Inadequate recording of medication prescribing decisions.

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. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate pain relief; 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

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. ”

Is this part of a recurring concern?

Yes — Failure to provide continuity of care staffing; Failure to provide continuity of patient care.

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; ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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; ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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; ”

Is this part of a recurring concern?

Yes — Inadequate review of long-term medication use.

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

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
Page 7 · response
Published 23 May 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

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
Page 3 · response
Published 23 May 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

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
Page 7 · response
Published 23 May 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

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
Page 5 · response
Published 23 May 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

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
Page 6 · response
Published 23 May 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

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
Page 4 · response
Published 23 May 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

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
Page 6 · response
Published 23 May 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

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
Page 7 · response
Published 23 May 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

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
Page 4 · response
Published 23 May 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

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
Page 4 · response
Published 23 May 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

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
Page 6 · response
Published 23 May 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

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
Page 3 · response
Published 23 May 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

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
Page 5 · response
Published 23 May 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

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
Page 5 · response
Published 23 May 2019

Open published response

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
Page 8 · response
Published 23 May 2019

Open published response

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
Page 9 · response
Published 23 May 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. 1

    Hold regular clinical meetings with the practice to maintain and monitor an action plan.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
  2. 2

    Review CCG governance for identifying practices needing support with robust clinical services.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
  3. 3

    Deliver a comprehensive safeguarding training programme for all practice staff.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
  4. 4

    Summarize medication-related incidents and require the practice to follow up and report actions to the CCG.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
  5. 5

    Ask patients during medication reviews about medicines obtained outside the GP practice, including hospital, relative-supplied and over-the-counter medicines.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
  6. 6

    Reset medication review dates for follow-up when requested blood tests remain outstanding.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
  7. 7

    Review prescribing and other quality markers to identify practice improvement needs.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.

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
Page 7 · response
Published 23 May 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

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
Page 7 · response
Published 23 May 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

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
Page 7 · response
Published 23 May 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

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
Page 7 · response
Published 23 May 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

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
Page 3 · response
Published 23 May 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

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
Page 5 · response
Published 23 May 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

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
Page 7 · response
Published 23 May 2019

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026