PFD report

Maria Susan McGAURAN · Prevention of Future Deaths report

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Issued 20 Dec 2021•Derby and Derbyshire

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised1

  1. Failure to undertake a medication review in response to known excessive, hoarded and erratic medication use
    Part of recurring concern: Failure to identify clinically significant medication risksPart of recurring concern: Failure to reliably conduct clinically required medication reviewsPart of recurring concern: Inadequate safeguards against misuse of medicines with abuse potential
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.5

  1. Action

    Prevent high-risk scheduled drugs from forming part of repeat prescriptions wherever possible.

    Stated by Alvaston Medical CentreStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
  2. Action

    Conduct structured, holistic medication reviews covering compliance, understanding, social history, lifestyle and medication changes.

    Stated by Alvaston Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 26 April 2022.
  3. Action

    Prevent prescriptions from being ordered automatically too far in advance of their due dates.

    Stated by Alvaston Medical CentreStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.

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 undertake a medication review in response to known excessive, hoarded and erratic medication use

Wider context from the report

“Ms McGauran had over several years been known to take excessive amounts of her codeine prescription medication. She had a history of hoarding medication and taking her medication erratically. Her family raised concerns with the Surgery as to her reliance on several differing medications. They requested that a review of her medications be undertaken. No such review was undertaken. The Surgery could have considered alternative pain management aids at an earlier stage (such as the Fentanyl patches considered only 1 month before death i.e. in October 2018) so as to prevent the risks of overdose. ”

Is this part of a recurring concern?

Yes — Failure to identify clinically significant medication risks; Failure to reliably conduct clinically required medication reviews; Inadequate safeguards against misuse of medicines with abuse potential.

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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

Prevent high-risk scheduled drugs from forming part of repeat prescriptions wherever possible.

Verbatim wording from the response

“3. Alvaston has also made it good practice, to ensure wherever possible, any high risk scheduled drugs do not form part of the repeat prescription. Furthermore, we have a robust system in place to ensure the prescribing of medications is not automatically ordered too far in advance of their due date. This reduces the risk of any patient's 'stock-piling' medication. This is an ongoing project that is constantly being reviewed and refined, and we continue to further assess which areas or medications would benefit from additional surveillance during the prescribing and issuing of the prescription.”

Source location

2022-0098-Response-from-Alvaston-Medical-Centre_Published
Page 1 · response
Published 26 April 2022

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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

Conduct structured, holistic medication reviews covering compliance, understanding, social history, lifestyle and medication changes.

Verbatim wording from the response

“1. Taking advantage of the expanding job roles within primary care, over the period January to February 2021, Alvaston Medical Centre recruited two clinical pharmacists to undergo patient medication reviews. The clinical pharmacist's area of professional expertise means they are ideally suited to conducting structured medication reviews of patients – including extensive knowledge of controlled drugs. As part of the medication review, they explore the patient’s compliance and understanding of their medication, along with addressing other concerns within their remit.”

Source location

2022-0098-Response-from-Alvaston-Medical-Centre_Published
Page 1 · response
Published 26 April 2022

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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

Prevent prescriptions from being ordered automatically too far in advance of their due dates.

Verbatim wording from the response

“3. Alvaston has also made it good practice, to ensure wherever possible, any high risk scheduled drugs do not form part of the repeat prescription. Furthermore, we have a robust system in place to ensure the prescribing of medications is not automatically ordered too far in advance of their due date. This reduces the risk of any patient's 'stock-piling' medication. This is an ongoing project that is constantly being reviewed and refined, and we continue to further assess which areas or medications would benefit from additional surveillance during the prescribing and issuing of the prescription.”

Source location

2022-0098-Response-from-Alvaston-Medical-Centre_Published
Page 1 · response
Published 26 April 2022

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

Continue assessing medications and prescribing areas that would benefit from additional surveillance.

Verbatim wording from the response

“3. Alvaston has also made it good practice, to ensure wherever possible, any high risk scheduled drugs do not form part of the repeat prescription. Furthermore, we have a robust system in place to ensure the prescribing of medications is not automatically ordered too far in advance of their due date. This reduces the risk of any patient's 'stock-piling' medication. This is an ongoing project that is constantly being reviewed and refined, and we continue to further assess which areas or medications would benefit from additional surveillance during the prescribing and issuing of the prescription.”

Source location

2022-0098-Response-from-Alvaston-Medical-Centre_Published
Page 1 · response
Published 26 April 2022

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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

Recruit two clinical pharmacists to support patient medication reviews.

Verbatim wording from the response

“1. Taking advantage of the expanding job roles within primary care, over the period January to February 2021, Alvaston Medical Centre recruited two clinical pharmacists to undergo patient medication reviews. The clinical pharmacist's area of professional expertise means they are ideally suited to conducting structured medication reviews of patients – including extensive knowledge of controlled drugs. As part of the medication review, they explore the patient’s compliance and understanding of their medication, along with addressing other concerns within their remit.”

Source location

2022-0098-Response-from-Alvaston-Medical-Centre_Published
Page 1 · response
Published 26 April 2022

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 positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    Stockpiling prescription medication cannot be totally eliminated because a determined patient may still accumulate medicines.

    Stated by Alvaston Medical CentreUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. 2

    Fentanyl patches would not be a viable safer pain-relief option because of their significant respiratory-depression risks.

    Stated by Alvaston Medical CentreDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  3. 3

    Citalopram and codeine at recommended doses should not cause toxicity; fatal toxicity likely required a substantial overdose.

    Stated by Alvaston Medical CentreDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Stockpiling prescription medication cannot be totally eliminated because a determined patient may still accumulate medicines.

Verbatim wording from the response

“None of the above actions have been taken as a response to Mrs McGauran's death (as said, these changes have come about as a result of our ongoing programme of improvement). Ultimately, the above will only reduce the risk of patients stockpiling prescription medications – there is no way to totally eliminate the possibility of a determined patient doing so. And we, of course, will continue to seek further opportunity to reduce that risk for our patients.”

Source location

2022-0098-Response-from-Alvaston-Medical-Centre_Published
Page 1 · response
Published 26 April 2022

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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

Fentanyl patches would not be a viable safer pain-relief option because of their significant respiratory-depression risks.

Verbatim wording from the response

“During this review it was noted that there have been reports of serious harm, including fatalities, associated with fentanyl patches in both opioid-naive patients and opioid-experienced patients. Up to May 2020, we have received 13 Yellow Card reports in which opioid-naive patients have experienced respiratory depression following use of fentanyl and additional Yellow Card reports in which respiratory depression was reported in patients switched from another opioid to an inappropriately high dose of fentanyl. There was no evidence of intentional overdose in these cases.”

Source location

2022-0098-Response-from-Alvaston-Medical-Centre_Published
Page 2 · response
Published 26 April 2022

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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

Citalopram and codeine at recommended doses should not cause toxicity; fatal toxicity likely required a substantial overdose.

Verbatim wording from the response

“Our clinical pharmacists have asked me to clarify with you the point raised in the inquest on the combined toxicity of the two prescribed medications, Citalopram and Codeine. To their knowledge, prescribing these two medications jointly – and taken to the recommended dosage - should not have led to drug toxicity. We are assuming, based on the concern you have raised, that the patient very significantly exceeded the recommended dosage of these 2 drugs (i.e. overdosed) and that was what caused the fatal level of toxicity?”

Source location

2022-0098-Response-from-Alvaston-Medical-Centre_Published
Page 1 · response
Published 26 April 2022

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