PFD report

Peter STOJILJKOVIC · Prevention of Future Deaths report

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Issued 14 Mar 2018•Manchester South

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
5

Named on the report

Responses found
1

Of 5 recipients

Stated actions
3

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. Lack of consistent and clear prescribing guidance across local and national lists
    Part of recurring concern: Inconsistent and unclear prescribing guidance
  2. Risk of patients obtaining melatonin from unlicensed internet sources
  3. Failure to communicate with community GPs before discharge about ongoing melatonin prescribing
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable communication of critical medication information to GPsPart of recurring concern: Unreliable communication of discharge medication information to care staffPart of recurring concern: Unreliable hospital discharge processes
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

    Review the case with the practice to identify further learning.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 16 June 2018.
  2. Action

    Discuss inappropriate advice to access medication online with Pennine Care and identify further action.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 16 June 2018.
  3. Action

    Raise how medication provision at discharge was handled with Pennine Care and identify required improvements.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 16 June 2018.

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

  1. Position

    Pennine Care is expected to respond directly on internet medication access and discharge medication provision because it has been separately contacted.

    Stated by NHS Greater Manchester Integrated Care BoardRedirects 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 consistent and clear prescribing guidance across local and national lists

Wider context from the report

“2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists. It was unclear why Stockport CCG took a different approach to other CCGs 3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty. ”

Is this part of a recurring concern?

Yes — Inconsistent and unclear prescribing guidance.

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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

Risk of patients obtaining melatonin from unlicensed internet sources

Wider context from the report

“4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it. This created a risk that he would have to access the drug from unlicensed sources. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 communicate with community GPs before discharge about ongoing melatonin prescribing

Wider context from the report

“1. The deceased had been prescribed melatonin whilst an in-patient. The inquest heard that post his discharge communication between the hospital; GP and Mr Stojiljkovic was such that he was unaware that his GP was prepared to prescribe melatonin in the community; 2. Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists. It was unclear why Stockport CCG took a different approach to other CCGs 3. The inquest heard that GPs are faced with a mixture of lists regarding prescribing. National and local. This results in GPs having to negotiate through a complex system when prescribing where there are grey areas that create uncertainty. 4. The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it. This created a risk that he would have to access the drug from unlicensed sources. 5. It was known whilst he was an in-patient that difficulties with prescribing melatonin in the community would arise. There was no evidence of any attempt to communicate with the GP prior to discharge to ensure a smooth discharge into the community. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable communication of critical medication information to GPs; Unreliable communication of discharge medication information to care staff; Unreliable hospital discharge processes.

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

Review the case with the practice to identify further learning.

Verbatim wording from the response

“1. We accept that from the information in the letter that there has been a breakdown in communication with the patient. You have written to the practice and we assume they will respond to that issue. However, our Medical Director will review the case with the practice to identify any further learning.”

Source location

2018-0077-Response-by-NHS-England
Page 1 · response
Published 16 June 2018

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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

Discuss inappropriate advice to access medication online with Pennine Care and identify further action.

Verbatim wording from the response

“4. We would not expect anybody to be told that they should access medication via the internet and we will discuss this with Pennine Care, and identify any further action that needs to be taken in respect of this finding. However, as you have written to Pennine Care I assume that they will respond to you directly on this issue. In addition, we will raise the issue of how the provision of medication at discharge was handled by Pennine Care, and again identify any improvements that they need to make.”

Source location

2018-0077-Response-by-NHS-England
Page 2 · response
Published 16 June 2018

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

Raise how medication provision at discharge was handled with Pennine Care and identify required improvements.

Verbatim wording from the response

“4. We would not expect anybody to be told that they should access medication via the internet and we will discuss this with Pennine Care, and identify any further action that needs to be taken in respect of this finding. However, as you have written to Pennine Care I assume that they will respond to you directly on this issue. In addition, we will raise the issue of how the provision of medication at discharge was handled by Pennine Care, and again identify any improvements that they need to make.”

Source location

2018-0077-Response-by-NHS-England
Page 2 · response
Published 16 June 2018

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

Pennine Care is expected to respond directly on internet medication access and discharge medication provision because it has been separately contacted.

Verbatim wording from the response

“4. We would not expect anybody to be told that they should access medication via the internet and we will discuss this with Pennine Care, and identify any further action that needs to be taken in respect of this finding. However, as you have written to Pennine Care I assume that they will respond to you directly on this issue. In addition, we will raise the issue of how the provision of medication at discharge was handled by Pennine Care, and again identify any improvements that they need to make.”

Source location

2018-0077-Response-by-NHS-England
Page 2 · response
Published 16 June 2018

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 CCG and Greater Manchester medication lists have the same interpretation, and practices may appropriately work with either list.

Verbatim wording from the response

“2. Melatonin is on both the CCG and the GM restricted lists currently, and CCGs across Greater Manchester aim to have consistent lists as far as possible. Although worded differently the interpretation would be the same in this case. We have not tracked the position of the GM list at the time of the incident, and accept that they may not have been consistent at that time. I acknowledge your point about the difficulties that practices face in navigating through the various different lists, for this reason, as long as a practice works with one of the lists, we would support them in their decision.”

Source location

2018-0077-Response-by-NHS-England
Page 1 · response
Published 16 June 2018

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