PFD report

Teresa Lonergan · Prevention of Future Deaths report

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Issued 14 Mar 2014•Inner South 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
2

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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

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Concerns raised2

  1. Failure to monitor consumption of prescribed controlled drugs
    Part of recurring concern: Failure to secure and control medicationPart of recurring concern: Unsafe medication administration
  2. Availability of potentially fatal quantities of morphine for overdose
    Part of recurring concern: Medication quantity controls failing to prevent unsafe access to excessive amounts
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 consumption of prescribed controlled drugs

Wider context from the report

“(1) At the scene the following bottles of morphine were found: 1 100 ml bottle 10mg/5mls 10% remaining, dated 21/02/12 1 100 ml bottle 10mg/5ml 30% remaining, dated 09/03/12 1 100 ml bottle 10mg/5ml 33% remaining, dated 08/05/12 1 100 ml bottle 10mg/5ml 75% remaining ? date 1 100 ml bottle 10mg/5ml, full, dated 13/07/12 and 3 loose strips of 10mg Zomorph with 23 of 28 remaining It was calculated that if the liquid morphine alone was considered there was 340mg available. The pathologist advised that 100 to 200mg would probably be sufficient to cause a fatality. (2) She was a retired matron. She was visited twice daily by her care worker, who opened her bottles for her as she was not able to do so herself. She did not report any medical instructions from doctors about administration or monitoring. Her GP issued repeat prescriptions of: 10mg Zomorph MR3 capsules 1 dse (issue up to 120), last issued 03/05/12 Morphine sulphate 10mg/5ml qds prn (issue up to 200mls)last issued 11/07/12. This was in addition to regular benzodiazepines and other non controlled analgesia. It was reported that she was visited several times a year by the surgery and kept in contact on the phone. There was no report of any monitoring of her consumption of controlled drugs, but the evidence from the general practice was read. She appeared to continue to draw prescriptions but not consume them as prescribed, thus building up a hoard, and providing the means for a deliberate overdose to be taken. ”

Is this part of a recurring concern?

Yes — Failure to secure and control medication; Unsafe medication administration.

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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

Availability of potentially fatal quantities of morphine for overdose

Wider context from the report

“(1) At the scene the following bottles of morphine were found: 1 100 ml bottle 10mg/5mls 10% remaining, dated 21/02/12 1 100 ml bottle 10mg/5ml 30% remaining, dated 09/03/12 1 100 ml bottle 10mg/5ml 33% remaining, dated 08/05/12 1 100 ml bottle 10mg/5ml 75% remaining ? date 1 100 ml bottle 10mg/5ml, full, dated 13/07/12 and 3 loose strips of 10mg Zomorph with 23 of 28 remaining It was calculated that if the liquid morphine alone was considered there was 340mg available. The pathologist advised that 100 to 200mg would probably be sufficient to cause a fatality. (2) She was a retired matron. She was visited twice daily by her care worker, who opened her bottles for her as she was not able to do so herself. She did not report any medical instructions from doctors about administration or monitoring. Her GP issued repeat prescriptions of: 10mg Zomorph MR3 capsules 1 dse (issue up to 120), last issued 03/05/12 Morphine sulphate 10mg/5ml qds prn (issue up to 200mls)last issued 11/07/12. This was in addition to regular benzodiazepines and other non controlled analgesia. It was reported that she was visited several times a year by the surgery and kept in contact on the phone. There was no report of any monitoring of her consumption of controlled drugs, but the evidence from the general practice was read. She appeared to continue to draw prescriptions but not consume them as prescribed, thus building up a hoard, and providing the means for a deliberate overdose to be taken. ”

Is this part of a recurring concern?

Yes — Medication quantity controls failing to prevent unsafe access to excessive amounts.

Open source report
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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