PFD report

Karl James Willis · Prevention of Future Deaths report

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Issued 24 Aug 2018•Exeter and Greater Devon

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.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

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 raised3

  1. Failure to ensure that the GP is informed
    Part of recurring concern: Failure to provide sufficient GP involvement in patient carePart of recurring concern: Failure to reliably escalate patient safety concerns to primary care
  2. Failure to check patients’ appropriate access to medication before self-certification
    Part of recurring concern: Failure to verify patient suitability before online sale of restricted medicines
  3. Toxicity of amitriptyline when taken in excessive amounts or with other medication
    Part of recurring concern: Toxicity risks from excessive or combined medication use
Responses linked to these concerns

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

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

  1. Position

    Private consultations, private-only clinicians and online prescribing fall outside the Board’s jurisdiction or control.

    Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.

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 ensure that the GP is informed

Wider context from the report

“(3) Permitting the patient the option of not having the GP informed removes an otherwise effective safeguard. The GP had worked with extreme care and supported the patient over many months to try and reduce his excessive reliance on polypharmacy. ”

Is this part of a recurring concern?

Yes — Failure to provide sufficient GP involvement in patient care; Failure to reliably escalate patient safety concerns to primary care.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to check patients’ appropriate access to medication before self-certification

Wider context from the report

“(2) Permitting the patient to “self certify” without any checks he can appropriately access this medication can allow the patient to give inaccurate answers, and therefore the questionnaire is open to deliberate abuse by those most vulnerable who have addiction problems ”

Is this part of a recurring concern?

Yes — Failure to verify patient suitability before online sale of restricted medicines.

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

Toxicity of amitriptyline when taken in excessive amounts or with other medication

Wider context from the report

“(1) Amitriptyline is well recognised to have toxic effects when taken in excessive amounts or in conjunction with other medication ”

Is this part of a recurring concern?

Yes — Toxicity risks from excessive or combined medication use.

Open source report

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

Private consultations, private-only clinicians and online prescribing fall outside the Board’s jurisdiction or control.

Verbatim wording from the response

“In choosing to access private health care, a patient is stepping outside the NHS, as a result, the Board has no jurisdiction over private consultations and none of the Board’s powers relating to community pharmacy, prescriptions or regulation would apply.”

Source location

2018-0256-Response-by-NHS-England
Page 2 · response
Published 26 September 2018

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 provider could not share consultation details with the patient’s GP because there was no legal justification to breach confidentiality.

Verbatim wording from the response

“You finally highlight the concern that Karl was given an option to refuse to have the details of his consultation with the private on-line provider to be shared with his own GP. We have checked the website for the provider which has been involved in this case and note that it is recommended that information is shared with a patient’s own GP. As you will appreciate, whilst most often in a patient’s best interest information to be shared, the bar at which it is appropriate for confidentiality to be breached is set high and in the tragic circumstance of Karl Willis, there would have been no legal justification to have breached his confidentiality and informed his GP or anyone else involved in his care.”

Source location

2018-0256-Response-by-NHS-England
Page 2 · response
Published 26 September 2018

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