PFD report

Ross REEVES · Prevention of Future Deaths report

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Issued 29 Mar 2018•Brighton and Hove

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
1

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
5

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 raised1

  1. Failure to provide adequate information during transfer of patients between GP practices
    Part of recurring concern: Unreliable healthcare patient transfer 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.4

  1. Action

    Clarify the digital issues causing corruption or loss of correspondence during GP-to-GP data transfer.

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

    Clarify the reasons for delayed paper-record transfers against Primary Care Support England’s contractual obligations.

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

    Alert local primary care to safe data transfer, robust coding and restricted medication quantities for high-risk patients, advising practices to adopt a blanket policy.

    Stated by NHS Surrey and Sussex 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.1

  1. Position

    NHSE commissions Primary Care Support England, which is responsible for the paper-record transfer service.

    Stated by NHS Surrey and Sussex 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

Failure to provide adequate information during transfer of patients between GP practices

Wider context from the report

“(1) The transfer of this patient to his new GP was likely ‘unsafe’. I am particularly concerned because in Brighton and Hove we have an extremely high rate of drug related deaths. It seems to me that there were clues to this man’s death and if there had been more information available to the new GP it is highly likely that they would have taken different action with regard to him. In particular, they may well have prescribed his medications weekly rather than monthly. At the Inquest it was clear that only he had access to the medications that he collected on the 3rd October, 2017 and that with regard to Gabapentin, Zomorph and Mirtazapine he took over one week’s worth of each. This caused his sudden collapse, his state of profound stupor and his ultimate death due to a lobar pneumonia which developed during the time he was in such a state of profound respiratory depression due to the drugs that he had been able to take. I would like it made clear that the Inquest is not a vehicle for apportioning blame however lessons must be learned and it was clear that better hand over of patients from one practice to another would provide a better chance for the manipulative patient who lies to his new GP to be picked up and dealt with adequately, hopefully preventing his death. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes.

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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

Clarify the digital issues causing corruption or loss of correspondence during GP-to-GP data transfer.

Verbatim wording from the response

“On registration, St Peter’s asked for a faxed summary (from RR’s previous Practice) that arrived promptly, as did an electronic summary via the ‘GP to GP’ process. Unfortunately, St Peter’s were unable to access details of correspondence via the electronic record; the digital explanation for this is unclear and requires urgent clarification, as full access was not possible until after RR’s death.”

Source location

2018-0093-Response-by-Brighton-Hove-CCG
Page 2 · 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

Clarify the reasons for delayed paper-record transfers against Primary Care Support England’s contractual obligations.

Verbatim wording from the response

“The paper records arrived on 12/12/2017 having been requested on 10/10/2017. The records were requested urgently; this delay is very concerning and warrants clarification as a priority.”

Source location

2018-0093-Response-by-Brighton-Hove-CCG
Page 2 · 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

Alert local primary care to safe data transfer, robust coding and restricted medication quantities for high-risk patients, advising practices to adopt a blanket policy.

Verbatim wording from the response

“1. Alert to local Primary Care, highlighting issues around safe transfer of data [paper and electronic] during patient transfer, robust coding and the importance of restricting quantities of medication in patients identified as high risk until relevant clinical notes are available, and a period of assessment has reassured the new practice that prescribed medicines are used according to directions. Practices will be advised to adopt a blanket policy thereby removing the need for negotiation with individual patients.”

Source location

2018-0093-Response-by-Brighton-Hove-CCG
Page 3 · 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

Have the Task and Finish group report on prescribing-safety and patient-transfer issues within six to eight weeks.

Verbatim wording from the response

“This Task and Finish group will aim to report over the next 6-8 weeks. In addition to covering the issues raised above, I envisage:”

Source location

2018-0093-Response-by-Brighton-Hove-CCG
Page 3 · response
Published 16 June 2018

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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

NHSE commissions Primary Care Support England, which is responsible for the paper-record transfer service.

Verbatim wording from the response

“3. Clarification as to reasons for delay in paper records arriving in the context of contractual obligation of Primary Care Support England. Commissioning of this service is via NHSE.”

Source location

2018-0093-Response-by-Brighton-Hove-CCG
Page 3 · response
Published 16 June 2018

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.1

  1. 1

    Set up a multidisciplinary Task and Finish group involving primary care, pharmacy, substance misuse, digital, public health, quality, safety and voluntary-sector representatives.

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

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    St Peter’s prescribed Zomorph, Gabapentin and Mirtazapine within recommended doses if taken correctly; detected benzodiazepines were not prescribed there.

    Stated by NHS Surrey and Sussex Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Time pressures make it impracticable to formally discuss every high-risk case in Primary Care.

    Stated by NHS Surrey and Sussex Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Set up a multidisciplinary Task and Finish group involving primary care, pharmacy, substance misuse, digital, public health, quality, safety and voluntary-sector representatives.

Verbatim wording from the response

“The CCG will set up a ‘Task and Finish’ group with input from Primary Care prescribers as well as Practice Managers, CCG and Community Pharmacists, Pavilions substance misuse service, the CCG digital team, Public Health colleagues, the CCG Quality and Safety Team and representatives from the Community and Voluntary sector. In terms of Primary Care we will specifically ask for input from The Arch Healthcare as their team has expertise in managing this cohort of patients.”

Source location

2018-0093-Response-by-Brighton-Hove-CCG
Page 3 · response
Published 16 June 2018

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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

St Peter’s prescribed Zomorph, Gabapentin and Mirtazapine within recommended doses if taken correctly; detected benzodiazepines were not prescribed there.

Verbatim wording from the response

“As recorded elsewhere, Zomorph, Gabapentin and Mirtazapine were prescribed via St Peter's. The doses of each [if taken correctly] were within recommended prescribing ranges. The benzodiazepines detected following death was not prescribed via St Peter's.”

Source location

2018-0093-Response-by-Brighton-Hove-CCG
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

Time pressures make it impracticable to formally discuss every high-risk case in Primary Care.

Verbatim wording from the response

“7. As noted elsewhere, St Peter’s do have regular structured discussions of challenging cases. This is not universal and is clearly good practice. Pressure on Primary Care time is a barrier and as a CCG we need to ensure maximal support for Primary Care to enable such discussions on a regular basis. Logistically it will not be possible for all high risk cases to be discussed and inevitably [as with RR] some cases may not be formally discussed.”

Source location

2018-0093-Response-by-Brighton-Hove-CCG
Page 4 · response
Published 16 June 2018

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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