PFD report

Jonathan Paul SZCZEPANSKI · Prevention of Future Deaths report

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Issued 17 May 2024•Greater Lincolnshire

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
7

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 of hospital discharge documentation to provide warnings on NSAID prescribing considerations and risk factors
    Part of recurring concern: Unreliable hospital discharge documentationPart of recurring concern: Unreliable hospital discharge processes
  2. Failure of NSAID prescribing software to automatically generate specific warning flags for prescribing considerations and risk factors
    Part of recurring concern: Unreliable clinical safety-alert systems
  3. Lack of local practitioner guidance on practical implementation of NICE NSAID prescribing issues documentation
    Part of recurring concern: Unreliable pharmacy clinical guidance and procedures
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.4

  1. Action

    Resend a reminder about co-prescribing PPIs with NSAIDs through the discharge prescribing safety work.

    Stated by NHS Lincolnshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 20 May 2024.
  2. Action

    Work with the Trust and safety lead to develop systems promoting safer NSAID prescribing after hospital discharge.

    Stated by NHS Lincolnshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 May 2024.
  3. Action

    Work with all practices to highlight the importance of using OptimiseRx and Eclipse prescribing safety tools.

    Stated by NHS Lincolnshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 May 2024.

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 hospital discharge documentation to provide warnings on NSAID prescribing considerations and risk factors

Wider context from the report

“(3) Where repeat prescriptions were issued on discharge of a patient from hospital back to community primary care, there was no warning on the discharge documentation to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI). ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge documentation; Unreliable hospital discharge processes.

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 NSAID prescribing software to automatically generate specific warning flags for prescribing considerations and risk factors

Wider context from the report

“(2) The software being used to prescribe NSAIDs did not automatically generate a specific warning flag to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI). ”

Is this part of a recurring concern?

Yes — Unreliable clinical safety-alert systems.

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 local practitioner guidance on practical implementation of NICE NSAID prescribing issues documentation

Wider context from the report

“(1) There is a lack of local practitioner guidance on the practical implementation of the NICE NSAIDs - prescribing issues documentation. ”

Is this part of a recurring concern?

Yes — Unreliable pharmacy clinical guidance and procedures.

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

Resend a reminder about co-prescribing PPIs with NSAIDs through the discharge prescribing safety work.

Verbatim wording from the response

“3. Where repeat prescriptions were issued on discharge of a patient from hospital back to community primary care, there was no warning on the discharge documentation to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI).”

Source location

2024-0271 Response from Lincolnshire Integrated Care Board
Page 2 · response
Published 20 May 2024

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

Work with the Trust and safety lead to develop systems promoting safer NSAID prescribing after hospital discharge.

Verbatim wording from the response

“3. Where repeat prescriptions were issued on discharge of a patient from hospital back to community primary care, there was no warning on the discharge documentation to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI).”

Source location

2024-0271 Response from Lincolnshire Integrated Care Board
Page 2 · response
Published 20 May 2024

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

Work with all practices to highlight the importance of using OptimiseRx and Eclipse prescribing safety tools.

Verbatim wording from the response

“2. The software being used to prescribe NSAIDs did not automatically generate a specific warning flag to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI).”

Source location

2024-0271 Response from Lincolnshire Integrated Care Board
Page 1 · response
Published 20 May 2024

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 a reminder about co-prescribing PPIs with NSAIDs to the Lincolnshire Formulary.

Verbatim wording from the response

“ICB response It is long-standing accepted practice, as per NICE guidelines, that PPIs should be considered as a co-prescription with NSAIDs for at risk patients.”

Source location

2024-0271 Response from Lincolnshire Integrated Care Board
Page 1 · response
Published 20 May 2024

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.3

  1. 1

    Share the case study and NICE guidance reminders at the Medicine Safety Network and Prescribing Forum meetings.

    Stated by NHS Lincolnshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 20 May 2024.
  2. 2

    Monitor safer discharge prescribing through the Quality Forum.

    Stated by NHS Lincolnshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 20 May 2024.
  3. 3

    Highlight NICE NSAID prescribing guidance in the next Medicines Optimisation newsletter and primary care Bulletin.

    Stated by NHS Lincolnshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 20 May 2024.

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 the case study and NICE guidance reminders at the Medicine Safety Network and Prescribing Forum meetings.

Verbatim wording from the response

“3. This will be shared as a case study at the Medicine Safety Network meeting and the Prescribing Forum, including a reminder of the NICE guidelines”

Source location

2024-0271 Response from Lincolnshire Integrated Care Board
Page 1 · response
Published 20 May 2024

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

Monitor safer discharge prescribing through the Quality Forum.

Verbatim wording from the response

“ICB response At the point of discharge from hospital a list of all medications is produced and is sent to the relevant GP practice. The ICB understands that the Trust is putting in place an electronic patient record that should make this more visible. We will work with the Trust to develop systems that promote safer prescribing which will include work with the safety lead to resend a reminder of the importance of co-prescribing a PPI with NSAID, and we plan to monitor this through our Quality forum.”

Source location

2024-0271 Response from Lincolnshire Integrated Care Board
Page 2 · response
Published 20 May 2024

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

Highlight NICE NSAID prescribing guidance in the next Medicines Optimisation newsletter and primary care Bulletin.

Verbatim wording from the response

“1. There is a lack of local practitioner guidance on the practical implementation of the NICE NSAIDs – prescribing issues documentation.”

Source location

2024-0271 Response from Lincolnshire Integrated Care Board
Page 1 · response
Published 20 May 2024

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