PFD report

Michael John Vince · Prevention of Future Deaths report

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Issued 27 Jun 2022•East London

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
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
8

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 raised4

  1. Failure to monitor the frequency of PRN medication administration
    Part of recurring concern: Unsafe medication administration
  2. Lack of meaningful review of insomnia medication prescriptions
    Part of recurring concern: Failure to reliably conduct clinically required medication reviews
  3. Failure to share dependence information with the mental health trust
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable inter-agency information sharing for coordinated care
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

    Update medication-monitoring practice and jointly monitor its implementation with the chief pharmacist.

    Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
  2. Action

    Hold practice staff meetings to explain the Z-Drug protocol and require repeat-prescription requests to be referred for medication review.

    Stated by High Street SurgeryStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
  3. Action

    Implement a local Z-Drug protocol requiring structured medication reviews at defined intervals and after relevant mental-health review.

    Stated by High Street SurgeryStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.

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

  1. Position

    Review of hypnotic prescriptions is assigned to the primary prescriber, with Trust clinicians reviewing prescriptions within their treatment scope.

    Stated by High Street SurgeryRedirects 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 monitor the frequency of PRN medication administration

Wider context from the report

“4. The frequency with which Mr Vince was administering his PRN ████████ was never monitored. ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

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 meaningful review of insomnia medication prescriptions

Wider context from the report

“2. No evidence exists to support that Mr Vince’s GP or community mental health team meaningfully reviewed his prescription ████████. ”

Is this part of a recurring concern?

Yes — Failure to reliably conduct clinically required medication reviews.

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 share dependence information with the mental health trust

Wider context from the report

“3. Evidence of Mr Vince’s dependence upon ████████ was not shared by his GP with the mental health trust. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable inter-agency information sharing for coordinated 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

Failure to limit prolonged prescribing of insomnia medication

Wider context from the report

“1. The NICE guidelines for ████████ indicate that it is a suitable medication for the short term treatment of insomnia, it advises against prolonged use due to risk of tolerance and withdrawal symptoms. Mr Vince is said to have been prescribed ████████ for 20 years. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

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

Update medication-monitoring practice and jointly monitor its implementation with the chief pharmacist.

Verbatim wording from the response

“The current practice at NELFT is that whoever prescribes the medication, is responsible for monitoring the compliance with medication administration regime. However, in light of learning from this inquest we have updated our practice as highlighted within the attached action plan and will monitor implementation of the updated practice jointly with the chief pharmacist.”

Source location

Response from North East London Foundation Trust
Page 2 · response
Published 23 September 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

Hold practice staff meetings to explain the Z-Drug protocol and require repeat-prescription requests to be referred for medication review.

Verbatim wording from the response

“C. Discussion and Education of Practice Staff”

Source location

Response from High St Surgery
Page 2 · response
Published 23 September 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

Implement a local Z-Drug protocol requiring structured medication reviews at defined intervals and after relevant mental-health review.

Verbatim wording from the response

“B. Implementation of Z-Drug Protocol”

Source location

Response from High St Surgery
Page 2 · response
Published 23 September 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

Audit and clinically review all patients prescribed Zopiclone over the previous two years, including structured reviews and a second-cycle review of repeat prescriptions.

Verbatim wording from the response

“A. Clinical Audit of all patients prescribed Zopiclone over the past 2 years:”

Source location

Response from High St Surgery
Page 2 · response
Published 23 September 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

Commence more proactive referral of patients appearing dependent on Z-Drug hypnotics to specialist mental-health services for review and advice.

Verbatim wording from the response

“For my part, I have commenced more proactive referral of patients who appear dependent upon Z-Drug hypnotics for review and advice by specialist NELFT Mental Health services. This has been assisted by the response of the NELFT to the Coronal recommendations and the discussion and collaboration that has resulted. My practice’s Z-Drug Protocol includes a requirement for structured medication review for patients on long term Z-Drugs with mental health issues, and a requirement to notify the Mental Health Team for those patients who request additional Z drugs.”

Source location

Response from High St Surgery
Page 3 · response
Published 23 September 2022

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

Review of hypnotic prescriptions is assigned to the primary prescriber, with Trust clinicians reviewing prescriptions within their treatment scope.

Verbatim wording from the response

“At that meeting the importance of proper communication between local GP’s, the NELFT Mental Health Team and other clinical services was discussed. It was agreed that review of hypnotics was the responsibility of the primary prescriber, but also the prescriptions should be reviewed by the Trust clinicians when in the scope of treatment provided by that clinician.”

Source location

Response from High St Surgery
Page 3 · response
Published 23 September 2022

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 Trust, through its pharmacy services, is responsible for the wider Z-drug prescribing audit and safe-prescribing training package.

Verbatim wording from the response

“The Trust committed to undertaking a wider audit of Z-Drug prescribing within the NELFT localities which will be led by the Trust pharmacy services. They will also be developing a safe-prescribing training package and will include education of local GP’s in their roll-out of this package.”

Source location

Response from High St Surgery
Page 3 · response
Published 23 September 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-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

    Conduct a pharmacy-led wider learning review and develop an action plan addressing learning from the inquest.

    Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
  2. 2

    Display information about the practice’s Z-Drug protocol in the waiting room for patients.

    Stated by High Street SurgeryStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
  3. 3

    Continue monitoring the implemented Z-Drug actions through regular practice meetings.

    Stated by High Street SurgeryStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.

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 a pharmacy-led wider learning review and develop an action plan addressing learning from the inquest.

Verbatim wording from the response

“We have taken the concerns expressed by you very seriously and undertook further consultations with the Chief Pharmacist and other members of the MDT. On 06/07/22 we arranged a wider NELFT learning review led by our pharmacy department and developed an action plan to address the identified further learning following the Inquest. The event was attended by health care professionals at NELFT and primary care including the practice which was directly involved in the care of Mr Vince.”

Source location

Response from North East London Foundation Trust
Page 1 · response
Published 23 September 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

Display information about the practice’s Z-Drug protocol in the waiting room for patients.

Verbatim wording from the response

“A notice has been placed in the practice waiting room for the information of patients regarding the practice’s Z-Drug protocol.”

Source location

Response from High St Surgery
Page 3 · response
Published 23 September 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 monitoring the implemented Z-Drug actions through regular practice meetings.

Verbatim wording from the response

“We will continue to monitor the above actions in our regular practice meetings.”

Source location

Response from High St Surgery
Page 3 · response
Published 23 September 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