PFD report

Eirwen Rebecca Hollister · Prevention of Future Deaths report

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Issued 11 Oct 2022•Stoke-on-Trent and North Staffordshire

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
1

Named on the report

Responses found
2

Of 1 recipient

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. Lack of a process to prevent prescriptions being issued before full GPO review following a prescribed-medication overdose
    Part of recurring concern: Failure to apply overdose-risk safeguards to medication prescribingPart 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.4

  1. Action

    Discuss the overdose policy and significant event analysis with all practice staff at the scheduled 15 November meeting.

    Stated by Heathview Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 14 October 2022.
  2. Action

    Review the overdose policy, discuss it with clinicians, and make it accessible to staff on the shared drive.

    Stated by Heathview Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 14 October 2022.
  3. Action

    Teach clinical staff how to action hospital letters concerning overdoses.

    Stated by Heathview Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 14 October 2022.

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 a process to prevent prescriptions being issued before full GPO review following a prescribed-medication overdose

Wider context from the report

“(1) Evidence was given during the inquest that there was no process or procedure in place to ensure that when a patient, registered with the GP practice, took an overdose of prescribed medication, no prescriptions were issued before a full review by a GPO was undertaken. . ”

Is this part of a recurring concern?

Yes — Failure to apply overdose-risk safeguards to medication prescribing; Unsafe medication prescribing.

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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 the overdose policy and significant event analysis with all practice staff at the scheduled 15 November meeting.

Verbatim wording from the response

“• The Policy and the significant event will be discussed with all the staff in a practice meeting on 15th November 2022”

Source location

Response from Heathview Medical Practice
Page 2 · response
Published 14 October 2022

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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

Review the overdose policy, discuss it with clinicians, and make it accessible to staff on the shared drive.

Verbatim wording from the response

“• The ‘Overdose Policy’ has been reviewed and discussed with all clinicians at Heathview Medical Practice on 21/10/22. The Policy is on the shared drive and can be accessed by all staff. Please find attached a copy of the Policy.”

Source location

Response from Heathview Medical Practice
Page 2 · response
Published 14 October 2022

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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

Teach clinical staff how to action hospital letters concerning overdoses.

Verbatim wording from the response

“• Teaching has been carried out to all clinical staff on how to action Docman letters (Clinical letters from Hospital) which involve overdoses on 21/10/2022”

Source location

Response from Heathview Medical Practice
Page 2 · response
Published 14 October 2022

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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

Complete a significant event analysis and discuss its findings with all clinicians.

Verbatim wording from the response

“• We have carried out a significant event analysis to identify any failings and learning points. The results of the significant analysis were discussed with all clinicians in a meeting on 21/10/22. Please find attached a copy of the significant event analysis.”

Source location

Response from Heathview Medical Practice
Page 2 · response
Published 14 October 2022

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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

    Share learning from the case across regional and national NHS communication channels.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 14 October 2022.

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

  1. 1

    The patient was not dual registered; she was dual consulting with clinicians at both practices during the relevant period.

    Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Share learning from the case across regional and national NHS communication channels.

Verbatim wording from the response

“Regionally, where applicable, learning will be shared across the region and nationally from this case using established communication channels within NHSE.”

Source location

Response from NHS England
Page 3 · response
Published 14 October 2022

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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

The patient was not dual registered; she was dual consulting with clinicians at both practices during the relevant period.

Verbatim wording from the response

“Following local investigations, it has been identified that Ms Hollister was not dual registered at both practices at the same time. However, it appears that she was “dual consulting” with clinicians at both practices between September 2021 and February 2022. At the time of her death, Ms Hollister was only registered at Heathview Practice in Tamworth (February 2022 – May 2022) and was not registered or receiving care from the Sutton Coldfield Group Practice.”

Source location

Response from NHS England
Page 2 · response
Published 14 October 2022

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