PFD report

Wendy Margaret Wilkes · Prevention of Future Deaths report

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Issued 20 Apr 2020•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.

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Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
11

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 raised4

  1. Lack of alert notes for prescribed medication
  2. Failure to ensure prescribers are aware of high alcohol use
    Part of recurring concern: Unsafe prescribing for patients consuming excessive alcohol
  3. Lack of follow-up review appointments for prescribed medication
    Part of recurring concern: Failure to reliably conduct clinically required medication reviewsPart of recurring concern: Unreliable arrangement and communication of patient appointments and follow-up
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

    Flag patients at risk from neuropathic medication and alcohol dependence, conduct medication reviews, and contact them about medication and alcohol consumption.

    Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.
  2. Action

    Train non-clinical staff to share intentional or accidental overdose information with practice GPs.

    Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.
  3. Action

    Develop and distribute guidance to practices on identifying and managing patients prescribed neuropathic drugs or opioids who may be alcohol-dependent.

    Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The named Clinical Commissioning Group is responsible for addressing the concerns raised about GP practice alert systems and prescribing risk assessment.

    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 alert notes for prescribed medication

Wider context from the report

“The inquest heard that there was no clear system of alert notes/follow up review appointments at her GP practice despite the extent of the prescribed medication; ”

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 ensure prescribers are aware of high alcohol use

Wider context from the report

“The inquest heard that the GP practice did not appear to have a system to ensure that prescribers were aware that her alcohol use was high and to assess the risk of mixing alcohol with the prescribed medication. ”

Is this part of a recurring concern?

Yes — Unsafe prescribing for patients consuming excessive alcohol.

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

Lack of follow-up review appointments for prescribed medication

Wider context from the report

“The inquest heard that there was no clear system of alert notes/follow up review appointments at her GP practice despite the extent of the prescribed medication; ”

Is this part of a recurring concern?

Yes — Failure to reliably conduct clinically required medication reviews; Unreliable arrangement and communication of patient appointments and follow-up.

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 assess the risk of mixing alcohol with prescribed medication

Wider context from the report

“The inquest heard that the GP practice did not appear to have a system to ensure that prescribers were aware that her alcohol use was high and to assess the risk of mixing alcohol with the prescribed medication. ”

Is this part of a recurring concern?

Yes — Failure to identify clinically significant medication risks; Unsafe prescribing for patients consuming excessive alcohol.

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

Flag patients at risk from neuropathic medication and alcohol dependence, conduct medication reviews, and contact them about medication and alcohol consumption.

Verbatim wording from the response

“Alert Note/Review System effective from 25 February 2020 The practice has identified relevant existing patients by running reports for patients coded on the practice’s clinical system as using neuropathic medication, cross referenced with patients coded with alcohol dependency who have had an intentional or accidental overdose. A “flag” is now placed on these patients’ medical records and a medication review is undertaken. The patients are then contacted to discuss their medication and their alcohol consumption.”

Source location

2020-0095-Response-from-Tameside-Glossop_Redacted
Page 2 · response
Published 18 May 2020

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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

Train non-clinical staff to share intentional or accidental overdose information with practice GPs.

Verbatim wording from the response

“To further support this process, non-clinical staff have been trained to ensure that information related to intentional or accidental overdoses are shared with the General Practitioners in the practice; so the process described above can be followed.”

Source location

2020-0095-Response-from-Tameside-Glossop_Redacted
Page 2 · response
Published 18 May 2020

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

Develop and distribute guidance to practices on identifying and managing patients prescribed neuropathic drugs or opioids who may be alcohol-dependent.

Verbatim wording from the response

“Tameside and Glossop Clinical Commissioning Group (CCG) actions ████████, Director of Commissioning, is accountable to ensure that in line with the Coroner’s request, the following actions will be undertaken:”

Source location

2020-0095-Response-from-Tameside-Glossop_Redacted
Page 2 · response
Published 18 May 2020

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

Issue an alert to all GP practices about alert notes, follow-up reviews and considering systems to identify high alcohol use during prescribing.

Verbatim wording from the response

“3. An alert will be issued to all GP practices to ensure that they have clear systems of alert notes/follow up review appointments for individuals with extensive prescribed medications. The alert also requests GP practices consider how their systems can alert prescribers to patients with high alcohol usage when prescribing medications to ensure effective risk assessments can be carried out.”

Source location

2020-0095-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership
Page 2 · response
Published 18 May 2020

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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 named Clinical Commissioning Group is responsible for addressing the concerns raised about GP practice alert systems and prescribing risk assessment.

Verbatim wording from the response

“I have noted that your Regulation 28 letter has also been sent to the Clinical Commissioning Group concerned and I will leave it to the named respondent to address the concerns which you have addressed. My letter therefore addresses the issues that fall within the remit of GMHSCP.”

Source location

2020-0095-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership
Page 2 · response
Published 18 May 2020

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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.7

  1. 1

    Review patients after an overdose, provide weekly prescriptions, and refer them to appropriate mental health, social prescribing, and drug and alcohol services.

    Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.
  2. 2

    Share and disseminate learning from the inquest and related review.

    Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.
  3. 3

    Monitor these safety issues through quality reporting to the Strategic Commissioning Board and discussion at primary-care governance meetings.

    Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 18 May 2020.
  4. 4

    Monitor key learning points and recommendations to ensure they become embedded within practice.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 18 May 2020.
  5. 5

    Present and share the relevant learning with the Greater Manchester Quality Board.

    Stated by NHS Greater Manchester Integrated Care BoardStatus unclearThe respondent did not make the status of this action clear when they made their response on 18 May 2020.
  6. 6

    Implement Standard 7’s medication-safety processes, including shared learning, peer review, incident reporting, remedial actions and review processes across localities.

    Stated by NHS Greater Manchester Integrated Care BoardStatus at responseThe respondent said that this action was partly complete when they made their response on 18 May 2020.
  7. 7

    Share the relevant learning with Greater Manchester service commissioners to support assurance of commissioned service quality.

    Stated by NHS Greater Manchester Integrated Care BoardStatus unclearThe respondent did not make the status of this action clear when they made their response on 18 May 2020.

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 patients after an overdose, provide weekly prescriptions, and refer them to appropriate mental health, social prescribing, and drug and alcohol services.

Verbatim wording from the response

“The process for patients who may unfortunately suffer from an intentional/accidental overdose in the future when the practice has been made aware of an overdose, is that the patient will be seen and reviewed by the Practice. Subsequently, in order to minimize the risks of future overdoses, all such patients will be placed on weekly prescriptions. The practice will refer patients to mental health services, social prescribing and drug and alcohol service as appropriate.”

Source location

2020-0095-Response-from-Tameside-Glossop_Redacted
Page 2 · response
Published 18 May 2020

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

Share and disseminate learning from the inquest and related review.

Verbatim wording from the response

“I trust that our actions offer reassurance that the CCG and the Practice have reflected on the evidence and findings provided at Mrs Wilkes’ Inquest. It is acknowledged that there has been a great deal of learning and reflection following the Inquest of Mrs Wilkes and we assure you that this learning has been shared and disseminated.”

Source location

2020-0095-Response-from-Tameside-Glossop_Redacted
Page 2 · response
Published 18 May 2020

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

Monitor these safety issues through quality reporting to the Strategic Commissioning Board and discussion at primary-care governance meetings.

Verbatim wording from the response

“We shall keep these issues under review as part of the quality monitoring reported to the Strategic Commissioning Board, whose meetings are held in public. Minutes are available on the Tameside and Glossop CCG website (https://www.tamesideandglossopccg.org/corporate/strategic-commissioning-board).”

Source location

2020-0095-Response-from-Tameside-Glossop_Redacted
Page 2 · response
Published 18 May 2020

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

Monitor key learning points and recommendations to ensure they become embedded within practice.

Verbatim wording from the response

“The Greater Manchester Health and Social Care Partnership (GMHSCP) is committed to improving outcomes for the population of Greater Manchester. In conclusion key learning points and recommendations will be monitored to ensure they are embedded within practice.”

Source location

2020-0095-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership
Page 3 · response
Published 18 May 2020

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

Present and share the relevant learning with the Greater Manchester Quality Board.

Verbatim wording from the response

“Actions taken or being taken to prevent reoccurrence across Greater Manchester.”

Source location

2020-0095-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership
Page 2 · response
Published 18 May 2020

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

Implement Standard 7’s medication-safety processes, including shared learning, peer review, incident reporting, remedial actions and review processes across localities.

Verbatim wording from the response

“Previously, across Greater Manchester, a set of nine standards were developed to improve quality and reduce unwarranted variation in the delivery of primary care. The standards were first developed in 2014 and a refreshed version implemented in 2018.”

Source location

2020-0095-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership
Page 2 · response
Published 18 May 2020

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

Share the relevant learning with Greater Manchester service commissioners to support assurance of commissioned service quality.

Verbatim wording from the response

“Actions taken or being taken to prevent reoccurrence across Greater Manchester.”

Source location

2020-0095-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership
Page 2 · response
Published 18 May 2020

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