PFD report

Courtney Jordan Mills · Prevention of Future Deaths report

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Issued 12 May 2014•Portsmouth and South East Hampshire

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

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

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Concerns raised2

  1. Failure to issue correct Clonodine prescriptions
    Part of recurring concern: Unsafe medication prescribing
  2. Failure to communicate and coordinate timely Clonodine supply
    Part of recurring concern: Unreliable communication of critical medication information to GPs
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.5

  1. Position

    If medication-continuity issues require national consideration, the Royal Pharmaceutical Society is suggested as the appropriate body to address them.

    Stated by Portsmouth Hospitals University NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 issue correct Clonodine prescriptions

Wider context from the report

“I was told that (quote): "Courtney was on a quantity of different medication for her conditions one of which is "Clonodine". Her parents reported that they had been having problems getting the correct prescriptions for this from the GP surgery (written as tablets instead of solution, wrong dosage etc) and this caused problems. This drug cannot just be stopped as the patient suffers from withdrawal symptoms and has to be weaned off gradually. The drug was ordered in by the Pharmacist and could take 5 days to get in so the prescription was always requested in advance of when it was required. Courtney's supply was running low and a prescription was collected by mother and taken to the pharmacy. She returned a few days later she was told that the prescription had been written wrongly and had been returned to the GP and she should have been called by them. Neither parent had received a call. Mother attended the surgery and was told that the prescription could not be done until they had spoken to Courtney's consultant at SGH, ████████ and they would be called when done. No calls received. Courtney's last dose of this medication was due to be given on Thursday morning and father continued to contact the GP surgery on Wednesday but was told it was not ready, he called again on Thursday to an answering machine stating the practice was closed for a training day. He was due to go into the surgery this morning to discuss the matter with the GPs." I was also told that Clonodine could be obtained from the pharmacy at Queen Alexandra Hospital for patients under the care of a consultant - as was Courtney. There had been a history of delay in her obtaining this medication due to communication difficulties between the hospital and her GP surgery. I believe such a problem could put other children's lives at risk in similar circumstances. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

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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 communicate and coordinate timely Clonodine supply

Wider context from the report

“I was told that (quote): "Courtney was on a quantity of different medication for her conditions one of which is "Clonodine". Her parents reported that they had been having problems getting the correct prescriptions for this from the GP surgery (written as tablets instead of solution, wrong dosage etc) and this caused problems. This drug cannot just be stopped as the patient suffers from withdrawal symptoms and has to be weaned off gradually. The drug was ordered in by the Pharmacist and could take 5 days to get in so the prescription was always requested in advance of when it was required. Courtney's supply was running low and a prescription was collected by mother and taken to the pharmacy. She returned a few days later she was told that the prescription had been written wrongly and had been returned to the GP and she should have been called by them. Neither parent had received a call. Mother attended the surgery and was told that the prescription could not be done until they had spoken to Courtney's consultant at SGH, ████████ and they would be called when done. No calls received. Courtney's last dose of this medication was due to be given on Thursday morning and father continued to contact the GP surgery on Wednesday but was told it was not ready, he called again on Thursday to an answering machine stating the practice was closed for a training day. He was due to go into the surgery this morning to discuss the matter with the GPs." I was also told that Clonodine could be obtained from the pharmacy at Queen Alexandra Hospital for patients under the care of a consultant - as was Courtney. There had been a history of delay in her obtaining this medication due to communication difficulties between the hospital and her GP surgery. I believe such a problem could put other children's lives at risk in similar circumstances. ”

Is this part of a recurring concern?

Yes — Unreliable communication of critical medication information to GPs.

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

If medication-continuity issues require national consideration, the Royal Pharmaceutical Society is suggested as the appropriate body to address them.

Verbatim wording from the response

“I am aware that maintaining correct medication when patients leave hospital is a significant problem across the NHS as it involves co-ordination between hospitals, GP practices, pharmacy and patients themselves, often with an important medication change made as a result of acute illness. While doctors clearly share responsibility for this, Pharmacists may be best placed to ensure safe processes around this. In the first instance, and if you feel that this issue needs to be considered on a national level, I would suggest that the Royal Pharmaceutical Society may be the best body to contact.”

Source location

2014-0224-Response-by-Portsmouth-Hospitals-NHS-Trust
Page 2 · response
Published 12 May 2014

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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

Existing assessment-unit and pharmacy arrangements would have enabled medication supply if the hospital had been approached, so no further Trust steps were proposed.

Verbatim wording from the response

“I understand from ████████ that the Clonidine was not in fact prescribed by Portsmouth Hospitals NHS Trust and our Pharmacy Department have also confirmed that we have no evidence to suggest that Queen Alexandra Hospital were approached for a supply of the drug, although had we been approached, we would have supplied it. In past situations like these, where community pharmacists have had trouble getting hold of non-routine medicines, the patient’s family have contacted our Children’s Assessment Unit (CAU) who have arranged for it to be prescribed by a doctor here and then we have dispensed it from the QAH pharmacy. This is a situation that we are used to and we would have done this in this case. However, had CAU been asked, they may have had a problem verifying the usual dosage, in which case we would have had to contact Southampton prior to writing the prescription.”

Source location

2014-0224-Response-by-Portsmouth-Hospitals-NHS-Trust
Page 1 · response
Published 12 May 2014

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 medication was not prescribed by the Trust, and there was no evidence that the hospital had been approached for a supply.

Verbatim wording from the response

“I understand from ████████ that the Clonidine was not in fact prescribed by Portsmouth Hospitals NHS Trust and our Pharmacy Department have also confirmed that we have no evidence to suggest that Queen Alexandra Hospital were approached for a supply of the drug, although had we been approached, we would have supplied it. In past situations like these, where community pharmacists have had trouble getting hold of non-routine medicines, the patient’s family have contacted our Children’s Assessment Unit (CAU) who have arranged for it to be prescribed by a doctor here and then we have dispensed it from the QAH pharmacy. This is a situation that we are used to and we would have done this in this case. However, had CAU been asked, they may have had a problem verifying the usual dosage, in which case we would have had to contact Southampton prior to writing the prescription.”

Source location

2014-0224-Response-by-Portsmouth-Hospitals-NHS-Trust
Page 1 · response
Published 12 May 2014

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 delay obtaining Clonidine solution was due to community supply constraints, not communication difficulties between the surgery and hospital.

Verbatim wording from the response

“████████ then spoke to ████████ on the telephone on 18.04.2013 regarding the Clonidine prescription. They discussed the transdermal option but ████████ felt there were medico-legal issues as it was off licence. ████████ felt that it was more appropriate that Southampton carried on supplying the medication and explained the difficulties to ████████ these being that there was a week’s delay, minimum, in sourcing Clonidine solution in the community and it was also impossible to issue it via the computer.”

Source location

2014-0224-Response-by-Waterside-Medical-Centre
Page 2 · response
Published 12 May 2014

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

Southampton Hospital should continue supplying Clonidine solution because community pharmacies could not readily obtain it.

Verbatim wording from the response

“████████ then spoke to ████████ on the telephone on 18.04.2013 regarding the Clonidine prescription. They discussed the transdermal option but ████████ felt there were medico-legal issues as it was off licence. ████████ felt that it was more appropriate that Southampton carried on supplying the medication and explained the difficulties to ████████ these being that there was a week’s delay, minimum, in sourcing Clonidine solution in the community and it was also impossible to issue it via the computer.”

Source location

2014-0224-Response-by-Waterside-Medical-Centre
Page 2 · response
Published 12 May 2014

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