James Duncan STEWART · Prevention of Future Deaths report

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Issued 4 Dec 2014•Bedfordshire and Luton

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

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 raised2

  1. Lack of medication-detail checks with the previous GP practice when prescribing responsibility changes
    Part of recurring concern: Unreliable medication reconciliation across care transitions
  2. Failure of the General Practitioner to confirm the correct medication rather than relying on nursing-home staff
    Part of recurring concern: Unclear responsibility for prescribing and medication advicePart of recurring concern: Unsafe medication prescribing

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. NHS Central East Integrated Care Board

    Develop and consult stakeholders on a medication-reconciliation protocol for transfers into care homes and registration with a new GP.

  2. NHS Central East Integrated Care Board

    Share the medication-reconciliation protocol with GP commissioners and NHS England’s Area Team for consideration of contractual compliance measures.

  3. NHS Central East Integrated Care Board

    Write an action plan to drive the medication-reconciliation work forward and monitor its progress through the Patient Safety and Quality Committee.

  4. NHS Central East Integrated Care Board

    Continue local efforts to improve information-technology systems and communication between care providers.

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

  1. NHS Central East Integrated Care Board

    National and incompatible IT systems prevent fully standardising electronic medicines information transfer between care providers.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. NHS Central East Integrated Care Board

    Prescribing GPs are responsible for ensuring medication meets patients’ clinical needs, rather than relying on non-clinical care-home staff to identify errors.

    Redirects 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

Lack of medication-detail checks with the previous GP practice when prescribing responsibility changes

Wider context from the report

“(1) There did not appear to be any system whereby when a new GP Practice is requested to prescribe medication from a patient’s Nursing Home the details are not checked with the previous Practice. Such a system would have highlighted the fact that Mr. Stewart’s Co-Careldopa medication had not been included. (2) It was felt by those giving evidence from the GP Practice, and from the two Nursing Homes, that the correct medication to be prescribed should be a matter for the General Practitioner to confirm rather than relying upon qualified staff from the Home. They also felt that the Clinical Commissioning Group were the obvious body to ensure that a robust and consistent system is put in place. ”

Is this part of a recurring concern?

Yes — Unreliable medication reconciliation across care transitions.

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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 of the General Practitioner to confirm the correct medication rather than relying on nursing-home staff

Wider context from the report

“(1) There did not appear to be any system whereby when a new GP Practice is requested to prescribe medication from a patient’s Nursing Home the details are not checked with the previous Practice. Such a system would have highlighted the fact that Mr. Stewart’s Co-Careldopa medication had not been included. (2) It was felt by those giving evidence from the GP Practice, and from the two Nursing Homes, that the correct medication to be prescribed should be a matter for the General Practitioner to confirm rather than relying upon qualified staff from the Home. They also felt that the Clinical Commissioning Group were the obvious body to ensure that a robust and consistent system is put in place. ”

Is this part of a recurring concern?

Yes — Unclear responsibility for prescribing and medication advice; 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

Develop and consult stakeholders on a medication-reconciliation protocol for transfers into care homes and registration with a new GP.

Verbatim wording from the response

“In the meantime, in liaison with GP colleagues, Bedfordshire Clinical Commissioning Group have developed a protocol for reconciliation of medications when people are transferred into care homes and are registered with a new GP. The protocol is under consultation with stakeholders in primary and social care. This will also be shared with the commissioners of General Practitioners, NHS England Area Team, for them to consider whether contractual actions can be taken to strengthen compliance with the protocol. An action plan has been written to drive this work forward and progress will be monitored by our Patient Safety and Quality Committee.”

Source location

2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
Page 2 · response
Published 4 December 2014

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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

Share the medication-reconciliation protocol with GP commissioners and NHS England’s Area Team for consideration of contractual compliance measures.

Verbatim wording from the response

“In the meantime, in liaison with GP colleagues, Bedfordshire Clinical Commissioning Group have developed a protocol for reconciliation of medications when people are transferred into care homes and are registered with a new GP. The protocol is under consultation with stakeholders in primary and social care. This will also be shared with the commissioners of General Practitioners, NHS England Area Team, for them to consider whether contractual actions can be taken to strengthen compliance with the protocol. An action plan has been written to drive this work forward and progress will be monitored by our Patient Safety and Quality Committee.”

Source location

2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
Page 2 · response
Published 4 December 2014

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

Write an action plan to drive the medication-reconciliation work forward and monitor its progress through the Patient Safety and Quality Committee.

Verbatim wording from the response

“In the meantime, in liaison with GP colleagues, Bedfordshire Clinical Commissioning Group have developed a protocol for reconciliation of medications when people are transferred into care homes and are registered with a new GP. The protocol is under consultation with stakeholders in primary and social care. This will also be shared with the commissioners of General Practitioners, NHS England Area Team, for them to consider whether contractual actions can be taken to strengthen compliance with the protocol. An action plan has been written to drive this work forward and progress will be monitored by our Patient Safety and Quality Committee.”

Source location

2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
Page 2 · response
Published 4 December 2014

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 local efforts to improve information-technology systems and communication between care providers.

Verbatim wording from the response

“Use of Information Technology (IT) solutions is key to standardising practice and improving patient safety particularly in relation to medicines management. Initiatives relating to electronic prescribing in acute and primary care which are in discussion stages but are currently underdeveloped across Health and Social Care and remain a barrier to efficient communication processes. We will continue to endeavour to improve IT systems as far as possible locally to improve communication between care providers.”

Source location

2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
Page 2 · response
Published 4 December 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

National and incompatible IT systems prevent fully standardising electronic medicines information transfer between care providers.

Verbatim wording from the response

“(1) There is currently no standardised system for when a GP practice is requested to prescribe medication for a new patient at a nursing home to include checks with the previous practice. Practices have developed local processes to facilitate accurate prescribing, however these remain subject to inconsistencies and interpretation. The main current IT software (called System One) in primary care does not have a process to share an accurate list of prescribed medicines and there is a delay in transfer of records to the new registered GP. This remains a national IT issue further complicated when GP practices are utilising IT systems which are not compatible.”

Source location

2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
Page 1 · response
Published 4 December 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

Prescribing GPs are responsible for ensuring medication meets patients’ clinical needs, rather than relying on non-clinical care-home staff to identify errors.

Verbatim wording from the response

“(2) It is agreed by our GP members that it is the responsibility of the prescribing GP that the correct medication is prescribed to meet the clinical needs of the person and it should not be dependent upon non-clinical staff in Care Homes to challenge the accuracy of this process.”

Source location

2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
Page 1 · response
Published 4 December 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