PFD report

William Stephen GREEN · Prevention of Future Deaths report

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Issued 28 Feb 2025•Shropshire, Telford and Wrekin

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
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 raised2

  1. Failure to record prescribed-drug counselling and safety advice
    Part of recurring concern: Failure to reliably record information and advice given to patientsPart of recurring concern: Inadequate safety-netting advice for patients and carers
  2. Lack of provision to record actions when patients lack capacity to understand medication explanations
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.3

  1. Action

    Incorporate this case into statutory senior-doctor safe-prescribing training, covering medication counselling, documentation and support for patients who do not understand.

    Stated by the Shrewsbury and Telford Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 4 March 2025.
  2. Action

    Update the medication counselling SOP to require documentation of every counselling episode and community-support referral on eScript.

    Stated by the Shrewsbury and Telford Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 March 2025.
  3. Action

    Take concerns about medication counselling and written records to an appropriate forum for discussion and consideration of necessary actions.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 4 March 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    NHS guidance, the Mental Capacity Act and local medicines policies provide an existing framework for treating patients who lack capacity.

    Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 record prescribed-drug counselling and safety advice

Wider context from the report

“(1) Once any patient at The Royal Shrewsbury Hospital is initiated on a new prescribed drug during an admission, no written record is ever made anywhere by anyone including pharmacy; nurses; doctors or consultants explaining or counselling the patient upon the possible side-effects or complications as a result of taking a specific prescribed drug; nor is there any written record on what to look out for and what to do in such circumstances and where they can get assistance. ”

Is this part of a recurring concern?

Yes — Failure to reliably record information and advice given to patients; Inadequate safety-netting advice for patients and carers.

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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

Lack of provision to record actions when patients lack capacity to understand medication explanations

Wider context from the report

“(2) No provision seems to be in place to record what should happen when the patient lacks capacity to understand such an explanation even when it is offered. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Incorporate this case into statutory senior-doctor safe-prescribing training, covering medication counselling, documentation and support for patients who do not understand.

Verbatim wording from the response

“Informed consent/counselling when prescribing a new medication: Treating clinicians have a duty and responsibility to ensure patients are aware of any material risk associated with planned treatment, this includes significant side effects of medication.”

Source location

Response from Shrewsbury and Telford NHS Trust
Page 2 · response
Published 4 March 2025

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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

Update the medication counselling SOP to require documentation of every counselling episode and community-support referral on eScript.

Verbatim wording from the response

“Record of counselling The counselling of a patient in hospital should be undertaken by the medical staff on prescribing the medication, by the nursing staff and pharmacy staff in preparation for discharge. All professions have a role in drug counselling, our pharmacists are the specialists in medication and counselling and have access to additional resources and referral services. Pharmacy led counselling/documentation:”

Source location

Response from Shrewsbury and Telford NHS Trust
Page 1 · response
Published 4 March 2025

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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

Take concerns about medication counselling and written records to an appropriate forum for discussion and consideration of necessary actions.

Verbatim wording from the response

“However, NHS England will take your concern about counselling, and keeping a written record of such counselling, to an appropriate forum for further discussion and consideration of any actions we need to take.”

Source location

Response from NHSE
Page 2 · response
Published 4 March 2025

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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

NHS guidance, the Mental Capacity Act and local medicines policies provide an existing framework for treating patients who lack capacity.

Verbatim wording from the response

“Regarding the capacity of patients, there is clear NHS guidance on how to proceed with treatment when someone may lack capacity. There is also legislation (The Mental Capacity Act 2005), which provides a framework for decision-making on behalf of people who lack capacity. We would expect Trusts to have their own local policies on the administration of new medications, and most Trusts’ Medicines Policies will contain guidance on counselling patients. However, as above, they may not direct that this counselling needs to be recorded in the patient’s notes, as this is not standard practice.”

Source location

Response from NHSE
Page 2 · response
Published 4 March 2025

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.4

  1. 1

    Adapt printed discharge summaries to highlight the NHS drug information website for medication counselling.

    Stated by the Shrewsbury and Telford Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 4 March 2025.
  2. 2

    Establish a multidisciplinary working group to develop, implement and embed actions addressing the identified concerns in future care.

    Stated by the Shrewsbury and Telford Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 March 2025.
  3. 3

    Introduce a patient medication leaflet signposting NHS drug information and guidance on high-risk medicines, side effects and immediate actions.

    Stated by the Shrewsbury and Telford Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 March 2025.
  4. 4

    Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share relevant learning and insights across national and regional NHS services.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 4 March 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Original-pack medicines supplied at discharge include Patient Information Leaflets describing medication risks and side-effects.

    Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Adapt printed discharge summaries to highlight the NHS drug information website for medication counselling.

Verbatim wording from the response

“Nurse led counselling:”

Source location

Response from Shrewsbury and Telford NHS Trust
Page 2 · response
Published 4 March 2025

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

Establish a multidisciplinary working group to develop, implement and embed actions addressing the identified concerns in future care.

Verbatim wording from the response

“Following the death of Mr Green and as a result of the internal investigation, a multi-disciplinary working group has been set up to address the concerns raised and ensure appropriate actions are developed, implemented and embedded in future care.”

Source location

Response from Shrewsbury and Telford NHS Trust
Page 3 · response
Published 4 March 2025

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

Introduce a patient medication leaflet signposting NHS drug information and guidance on high-risk medicines, side effects and immediate actions.

Verbatim wording from the response

“• A new patient medication leaflet has been designed and is being introduced to help provide further patient information. This leaflet will signpost patients to the NHS drug information website that has patient directed information on many of the drugs prescribed, including specific information on high-risk drugs and immediate actions to take for serious side-effects. This leaflet will be available by September 2025; it has been drafted and is currently being taken through the trust accessibility and governance processes. ○ The community services outlined below will supplement the patient information leaflet for those patients where the leaflet is not adequate.”

Source location

Response from Shrewsbury and Telford NHS Trust
Page 2 · response
Published 4 March 2025

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

Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share relevant learning and insights across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of William, are shared across the NHS at both a national and regional level and helps us”

Source location

Response from NHSE
Page 2 · response
Published 4 March 2025

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

Original-pack medicines supplied at discharge include Patient Information Leaflets describing medication risks and side-effects.

Verbatim wording from the response

“It should also be noted that, on discharge from hospital, patients will be provided with the ‘original pack’ medication, and these will contain the Patient Information Leaflet (PIL) which outlines the risks and side-effects. In the case of Lamotrigine, the PIL states:”

Source location

Response from NHSE
Page 2 · response
Published 4 March 2025

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