PFD report

Bruce Lee Houghton · Prevention of Future Deaths report

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Issued 18 Mar 2021•Manchester North

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
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
19

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 raised2

  1. Failure to complete annual medication reviews
    Part of recurring concern: Failure to reliably conduct clinically required medication reviews
  2. Failure to ask patients about over-the-counter medication during medication reviews
    Part of recurring concern: Failure to reliably conduct clinically required medication reviewsPart of recurring concern: Failure to reliably verify medication information during care assessments
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.11

  1. Action

    Recruit three additional permanent salaried GPs.

    Stated by The Uplands Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
  2. Action

    Participate in monthly multidisciplinary meetings with mental health, social care and other providers, including network pharmacist medication reviews for people of concern.

    Stated by The Uplands Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
  3. Action

    Share the medication-review questionnaire with partner practices and Manchester Health and Social Care Partnership for feedback and good-practice dissemination.

    Stated by The Uplands Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The questionnaire may not be embeddable in the current clinical system because of its limitations, until the Practice moves to a new system.

    Stated by The Uplands Medical PracticeUnable to actThe respondent said that a constraint prevented them from taking the relevant 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 complete annual medication reviews

Wider context from the report

“2. The Court heard the deceased had not had his annual medication review. The court heard evidence that at these reviews the patients are not asked about any over the counter medication they may purchase in addition to their prescribed medication. ”

Is this part of a recurring concern?

Yes — Failure to reliably conduct clinically required medication reviews.

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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 ask patients about over-the-counter medication during medication reviews

Wider context from the report

“2. The Court heard the deceased had not had his annual medication review. The court heard evidence that at these reviews the patients are not asked about any over the counter medication they may purchase in addition to their prescribed medication. ”

Is this part of a recurring concern?

Yes — Failure to reliably conduct clinically required medication reviews; Failure to reliably verify medication information during care assessments.

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

Recruit three additional permanent salaried GPs.

Verbatim wording from the response

“10. The medication review questionnaire and when it should be used will be included in the Practice’s prescribing policy and in-house Practice training on conducting a good medication review will be set up which I will lead. I will be assisted by the Practice manager. The first training on this will occur once the new GPs are in post. The training will also be provided for all new staff as part of their induction, and they will be asked to review the Practice’s prescribing policy. The practice aims to share this fully for feedback at the next practice meeting in August 2021 (17th August 2021) with a view to implementing it thereafter.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 2 · response
Published 24 May 2021

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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

Participate in monthly multidisciplinary meetings with mental health, social care and other providers, including network pharmacist medication reviews for people of concern.

Verbatim wording from the response

“2. Ms Kearsley specified in the Regulation 28 report that her concern related to the fact that the Court heard that the deceased had not had his annual medication review and that the Court heard evidence that at these reviews the patients were not asked about any over the counter medication they may purchase in addition to their prescribed medication.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 1 · response
Published 24 May 2021

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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-review questionnaire with partner practices and Manchester Health and Social Care Partnership for feedback and good-practice dissemination.

Verbatim wording from the response

“7. This questionnaire will be shared with the 3 other GP practices that are involved in the multidisciplinary team and will also be shared with Manchester Health and Social care Partnership for their views to see if it can be improved in any way and to promote good practice. I have already liaised with Manchester Health and Social Care Partnership to ask for their support and ████████, Senior Primary care Manager for Quality Improvement across Greater Manchester has informed me she will investigate how they can assist. Once this feedback has been received the Practice will look to embed the questionnaire within the current clinical system (Vision) although due to its limitations this may not be possible until the Practice moves to a new clinical system.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 2 · response
Published 24 May 2021

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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

Create a standardised medication-review questionnaire prompting enquiries about over-the-counter medicines and supplements at prescribing and annual reviews.

Verbatim wording from the response

“6. The Practice is in the process of creating a standardised medication review template based on good medical practice which will include a prompt to routinely trigger an enquiry as to if the patient is taking any over the counter medication, or supplements at the point of prescribing and at annual reviews. The clinical staff at the practice will all be made aware that they are to complete this questionnaire when prescribing new medication to a patient or when they are conducting a medication review.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 2 · response
Published 24 May 2021

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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

Move to a clinical IT system with integrated prescribing-safety prompts, medication-review prompts and visual reminders.

Verbatim wording from the response

“8. The Practice along with all the practices in Bury is in the process of moving to a new clinical IT system and it is our understanding that this has integrated prompts to improve the prescribing safety. This should assist staff who are prescribing in when it is appropriate to conduct a medication review and provide visual reminders. The Practice is due to have the new system in place by March 2022.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 2 · response
Published 24 May 2021

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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

Create and monthly review an electronic, traffic-light safety net to prioritise health checks and medication reviews for higher-risk mental health patients.

Verbatim wording from the response

“14. The higher risk mental health patients will be invited for a health check first and then subsequently all patients with known mental health conditions will be invited for a medication review. The Practice will aim to complete medication reviews of the higher risk patients with serious mental health conditions by the end of December 2021 with all patients having completed this by March 2022. An electronic document will be created as a safety net to prioritise these patients and reviewed monthly with the support of a mental health champion to ensure the patient has a health check followed by a medication review with a GP or pharmacist. This document will be completed by the end of August 2021, and a traffic light system will be used to identify patients needing urgent, medium, and less urgent reviews in order of priority.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 3 · response
Published 24 May 2021

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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

Recall patients with serious mental health conditions for detailed structured medication reviews, with Mental Health Lead oversight and dedicated administrative support.

Verbatim wording from the response

“13. As part of the Covid recovery the Practice is in the process of sending out invites as part of the recall system. The Practice will prioritise the completion of a detailed structured medication review for all patients with serious mental health conditions as defined in the Quality Outcomes Framework (QOF). Mr. Houghton would have been included in this group of patients. As the Mental Health Lead for the Practice, I will have oversight of this process. A dedicated member of staff will manage this, and the Practice is looking to train up a mental health champion to support this. We expect to have this in place by the end of August 2021.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 3 · response
Published 24 May 2021

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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

Employ a permanent pharmacist with medication-review competency and responsibility for improving the prescribing policy and questionnaire.

Verbatim wording from the response

“11. The Practice has employed a permanent pharmacist who is set to join in October 2021, after a thorough competency-based interview which specifically included questions about competency in conducting medication reviews and if they were routinely enquiring about over the counter medications as part of these. This was important to the Practice to ensure the pharmacist understands the goals of the Practice. The permanent pharmacist will then have an influence on the prescribing policy and the medication”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 2 · response
Published 24 May 2021

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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

Engage Royal College of General Practitioners practice-development support to review Practice processes and planned safety measures.

Verbatim wording from the response

“15. The Practice is engaging the practice development support of the Royal College of GPs to review the Practice processes currently in place and the plans shared above, for feedback and review. I would be happy to provide a further update to the coroner regarding the progress in November 2021 if that is acceptable.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 3 · response
Published 24 May 2021

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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

Include the medication-review questionnaire in the prescribing policy and provide medication-review training for clinical and new staff.

Verbatim wording from the response

“10. The medication review questionnaire and when it should be used will be included in the Practice’s prescribing policy and in-house Practice training on conducting a good medication review will be set up which I will lead. I will be assisted by the Practice manager. The first training on this will occur once the new GPs are in post. The training will also be provided for all new staff as part of their induction, and they will be asked to review the Practice’s prescribing policy. The practice aims to share this fully for feedback at the next practice meeting in August 2021 (17th August 2021) with a view to implementing it thereafter.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 2 · response
Published 24 May 2021

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

Provide local teams with advice and guidance supporting shared decision-making and appropriately timed medication reviews.

Verbatim wording from the response

“• GM Medicines Management Group (GMMMG) to provide advice and guidance for local teams to implement, including support to ensure shared decision making with patients and medication reviews occurring on an ideally annual (or sooner if required) basis.”

Source location

2021-0160-Response-from-GMCA_Published
Page 2 · response
Published 24 May 2021

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 questionnaire may not be embeddable in the current clinical system because of its limitations, until the Practice moves to a new system.

Verbatim wording from the response

“7. This questionnaire will be shared with the 3 other GP practices that are involved in the multidisciplinary team and will also be shared with Manchester Health and Social care Partnership for their views to see if it can be improved in any way and to promote good practice. I have already liaised with Manchester Health and Social Care Partnership to ask for their support and ████████, Senior Primary care Manager for Quality Improvement across Greater Manchester has informed me she will investigate how they can assist. Once this feedback has been received the Practice will look to embed the questionnaire within the current clinical system (Vision) although due to its limitations this may not be possible until the Practice moves to a new clinical system.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 2 · response
Published 24 May 2021

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

Local teams are responsible for implementing Greater Manchester medicines advice and guidance, while GMMMG provides supporting advice.

Verbatim wording from the response

“• GM Medicines Management Group (GMMMG) to provide advice and guidance for local teams to implement, including support to ensure shared decision making with patients and medication reviews occurring on an ideally annual (or sooner if required) basis.”

Source location

2021-0160-Response-from-GMCA_Published
Page 2 · response
Published 24 May 2021

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

Existing GP medication reviews and PCN Structured Medication Reviews are considered sufficient to address medication-review concerns.

Verbatim wording from the response

“I am advised that GP practices are expected to review patient medication on a regular basis as part of the primary medical services provided under the GP contract.”

Source location

2021-0160-Response-from-Department-of-Health-Social-Care_Published
Page 1 · response
Published 24 May 2021

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.8

  1. 1

    Employ a permanent salaried GP to increase Practice staffing capacity.

    Stated by The Uplands Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
  2. 2

    Prioritise vulnerable patients for permanent senior GPs and clinicians rather than locum clinicians whenever possible.

    Stated by The Uplands Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
  3. 3

    Hold daily informal clinical huddles to share information about patients needing review or further input.

    Stated by The Uplands Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
  4. 4

    Use the clinical IT system to restrict prescriptions and prevent patients from over-ordering medication.

    Stated by The Uplands Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
  5. 5

    Serve as the Practice’s Mental Health and Safeguarding Lead.

    Stated by The Uplands Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
  6. 6

    Undertake further review of potential safeguarding issues and care concerns.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
  7. 7

    Monitor key learning points and recommendations to ensure they become embedded in practice.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
  8. 8

    Disseminate relevant medicines advice, guidance and learning to providers, professionals and governance forums across Greater Manchester.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.

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

Employ a permanent salaried GP to increase Practice staffing capacity.

Verbatim wording from the response

“10. The medication review questionnaire and when it should be used will be included in the Practice’s prescribing policy and in-house Practice training on conducting a good medication review will be set up which I will lead. I will be assisted by the Practice manager. The first training on this will occur once the new GPs are in post. The training will also be provided for all new staff as part of their induction, and they will be asked to review the Practice’s prescribing policy. The practice aims to share this fully for feedback at the next practice meeting in August 2021 (17th August 2021) with a view to implementing it thereafter.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 2 · response
Published 24 May 2021

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

Prioritise vulnerable patients for permanent senior GPs and clinicians rather than locum clinicians whenever possible.

Verbatim wording from the response

“4. A change that has already been implemented at the Practice is that patients who are seen as vulnerable will be seen by more permanent senior GPs and clinicians rather than locum GPs whenever possible to preserve continuity of care in patients that need it the most.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 2 · response
Published 24 May 2021

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

Hold daily informal clinical huddles to share information about patients needing review or further input.

Verbatim wording from the response

“12. If the Practice receives information regarding a patient from other organisations or staff members that cause concern, then that patient will be invited for a review by a doctor. As the mental health lead, I regularly attend the Neighborhood MDT meetings which allows for those patients with serious mental health conditions or flagged as vulnerable to be reviewed at the Practice by me as part of the actions with input from the network pharmacist allowing for a more detailed (structured) medication review. Staff at the Practice are aware of the importance of flagging any patients that may be causing concern, and these are flagged to me or the on-call GP in my absence. The Practice has since May 2021 started daily informal clinical huddles and this has been working well in sharing information about patients that may require review or further input.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 3 · response
Published 24 May 2021

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

Use the clinical IT system to restrict prescriptions and prevent patients from over-ordering medication.

Verbatim wording from the response

“5. Another change that has already been implemented at the Practice since Mr. Houghton’s death is that clinical staff can place restrictions on prescriptions using the current IT system to prevent patients from over ordering medication. This update was received in a clinical meeting in February 2021 and included in the prescribing policy which is shared with new clinicians on induction and available on the Practice shared portal.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 2 · response
Published 24 May 2021

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

Serve as the Practice’s Mental Health and Safeguarding Lead.

Verbatim wording from the response

“1. I am a GP Partner at The Uplands Medical Practice (‘the Practice’) and I have been a GP at the Practice for 4 years. I am providing this response on behalf of the Practice. I am also now the Mental Health and Safeguarding Lead for the Practice.”

Source location

2021-0160-Response-from-Uplands-Medical-Practice_Published
Page 1 · response
Published 24 May 2021

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

Undertake further review of potential safeguarding issues and care concerns.

Verbatim wording from the response

“• There are potential safeguarding issues/ care concerns, which will be subject to further review.”

Source location

2021-0160-Response-from-GMCA_Published
Page 3 · response
Published 24 May 2021

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 key learning points and recommendations to ensure they become embedded in practice.

Verbatim wording from the response

“In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. GMHSCP is committed to improving outcomes for the population of Greater Manchester.”

Source location

2021-0160-Response-from-GMCA_Published
Page 3 · response
Published 24 May 2021

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

Disseminate relevant medicines advice, guidance and learning to providers, professionals and governance forums across Greater Manchester.

Verbatim wording from the response

“• Communication out to all relevant providers to refresh on the range of materials which would be of use to prevent a future occurrence: ○ GM polypharmacy resource pack, GM Neuropathic Pain Guidance, GM Opioid Resource Pack, GM Antipsychotics in dementia ○ In addition the full range of resources available at www.gmmmg.nhs.net and NICE etc. ○ NICE guidance on chronic pain https://www.nice.org.uk/guidance/ng193, which as noted above, suggests many other options to pharmacological management”

Source location

2021-0160-Response-from-GMCA_Published
Page 2 · response
Published 24 May 2021

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