PFD report

Stephen James Morris · Prevention of Future Deaths report

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Issued 29 Aug 2014•Blackpool and the Fylde

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
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
1

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. Failure to exchange sufficient relevant mental health information during cross-area transitions
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unsafe coordination and continuity during mental health service transfers
  2. Prescribing medication that is not preferred for a known mental-health condition without discussion with the responsible mental-health care team
    Part of recurring concern: Insufficient multi-disciplinary coordination in mental health carePart of recurring concern: Unsafe medication prescribing
  3. Failure to confirm mental-health treatment information with the responsible hospital care team before prescribing medication
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unsafe medication prescribing
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.1

  1. Action

    Request written confirmation from the Consultant Psychiatrist or Community Nurse Practitioner for future prescription changes.

    Stated by MDU Services LimitedStated plannedThe respondent said that this action was planned when they made their response on 27 November 2014.

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

  1. Position

    The prescription was not based solely on verbal patient information; the relevant hospital office was contacted to verify recommendations.

    Stated by MDU Services LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 exchange sufficient relevant mental health information during cross-area transitions

Wider context from the report

“Having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because: • I am concerned that there was a limited exchange of information as regards Stephen and his mental health between the mental health professionals in Cheshire and their counterparts in Blackpool. • By the time that Stephen came to Blackpool for what turned out to be the final time the professionals in Blackpool did not have a detailed picture of how Stephen had presented during recent weeks in relation to his mental health. • When individuals with a similar mental health history as Stephen do move from one area of the country to another there is the potential for a mental health team to find themselves with less detailed relevant information than may be the case for a similar individual who has recently been residing within the immediate area. I am concerned that the quality of exchange of information needs to be such that when mental health professionals find themselves dealing with such an individual that they have as much relevant information as possible to be able to assess the risk such a patient poses and to respond accordingly. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unsafe coordination and continuity during mental health service transfers.

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

Prescribing medication that is not preferred for a known mental-health condition without discussion with the responsible mental-health care team

Wider context from the report

“Having concluded this inquest, I now write to you to confirm that in my view you should take action because: • I am concerned that medication was prescribed to a Patient you knew had previously been referred to the local hospital Trust in respect of his mental health and the diagnosis that had been made. • That you prescribed the medication on the basis of verbal information provided by the Patient rather than seeking some confirmation from those within the Hospital Trust with responsibility for the Patient's mental health care provision. • That knowing the diagnosis, you prescribed medication you acknowledged was not the preferred medication for this Patient's condition and seemingly in the absence of discussion with those who had responsibility for the Patient’s mental health care. I would therefore be obliged if the Trust would write to me in due course to confirm what steps if any you propose to take to address these concerns. ”

Is this part of a recurring concern?

Yes — Insufficient multi-disciplinary coordination in mental health care; Unsafe medication prescribing.

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 confirm mental-health treatment information with the responsible hospital care team before prescribing medication

Wider context from the report

“Having concluded this inquest, I now write to you to confirm that in my view you should take action because: • I am concerned that medication was prescribed to a Patient you knew had previously been referred to the local hospital Trust in respect of his mental health and the diagnosis that had been made. • That you prescribed the medication on the basis of verbal information provided by the Patient rather than seeking some confirmation from those within the Hospital Trust with responsibility for the Patient's mental health care provision. • That knowing the diagnosis, you prescribed medication you acknowledged was not the preferred medication for this Patient's condition and seemingly in the absence of discussion with those who had responsibility for the Patient’s mental health care. I would therefore be obliged if the Trust would write to me in due course to confirm what steps if any you propose to take to address these concerns. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unsafe medication prescribing.

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

Request written confirmation from the Consultant Psychiatrist or Community Nurse Practitioner for future prescription changes.

Verbatim wording from the response

“This is incorrect. It is clear from the GP records and ████████ evidence that following his consultation, he telephoned ████████ office and verified the position as to the recommendations made by the Community Nurse Practitioner. ████████ however confirms that it is his standard practice to verify information from the patients as to medication changes and he did so in this case by telephoning ████████ office. From an administration perspective, ████████ will ensure that he in future requests that the Consultant Psychiatrist or Community Nurse Practitioner confirm any change of prescription in writing. Given that the patient was deemed to require that medication, it would have been inappropriate for ████████ to have deferred issuing the prescription pending the receipt of written confirmation.”

Source location

2014-0522-Response-by-MDU-Services-Limited
Page 2 · response
Published 27 November 2014

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 prescription was not based solely on verbal patient information; the relevant hospital office was contacted to verify recommendations.

Verbatim wording from the response

“This is incorrect. It is clear from the GP records and ████████ evidence that following his consultation, he telephoned ████████ office and verified the position as to the recommendations made by the Community Nurse Practitioner. ████████ however confirms that it is his standard practice to verify information from the patients as to medication changes and he did so in this case by telephoning ████████ office. From an administration perspective, ████████ will ensure that he in future requests that the Consultant Psychiatrist or Community Nurse Practitioner confirm any change of prescription in writing. Given that the patient was deemed to require that medication, it would have been inappropriate for ████████ to have deferred issuing the prescription pending the receipt of written confirmation.”

Source location

2014-0522-Response-by-MDU-Services-Limited
Page 2 · response
Published 27 November 2014

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

Prescribing medication after hospital mental-health referral was conventional within multidisciplinary care and was not inherently concerning.

Verbatim wording from the response

“The nature of the concern expressed in this point is unclear. Given the multi-disciplinary approach of medical care within the NHS, it is entirely conventional for GP to prescribe medication in line with recommendations from other medical practitioners from the Hospital Trust or from tertiary services.”

Source location

2014-0522-Response-by-MDU-Services-Limited
Page 2 · response
Published 27 November 2014

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

Using the existing medication was not shown to be unsafe: it had been tolerated previously and the subsequent psychiatrist did not change it.

Verbatim wording from the response

“Within the GP records, there is a letter dated 17th June 2013 from the deceased’s Psychiatrist, (copy enclosed) which confirms that he was aware of the medication that the deceased was taking as at 4th June 2013, the date of their consultation. Under “Current medication”, he lists “Mirtazapine 45mg od” and also “Lithium 1200mg daily”. He states in his letter “I have not made any changes to his current medication as he tells me that he is happy with this although the treatment regime he is on isn’t ideal for a diagnosis of Bipolar Disorder, i.e. The anti-depressant. Ideally, I would like to see Steven for a longer appointment to be able to take detailed history...we will try to arrange that for the future.””

Source location

2014-0522-Response-by-MDU-Services-Limited
Page 2 · response
Published 27 November 2014

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