PFD report

Elaine Michelle Inns · Prevention of Future Deaths report

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Issued 26 Aug 2021•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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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 raised2

  1. Failure to address continued prescription of liquid morphine despite non-adherence to dosage instructions
  2. Failure to account for significant alcohol use when prescribing powerful painkillers
    Part of recurring concern: Failure to identify clinically significant medication risksPart of recurring concern: Unsafe medication prescribingPart of recurring concern: Unsafe prescribing for patients consuming excessive alcohol
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.2

  1. Action

    Work with system colleagues to ensure adherence to best-practice opiate prescribing guidance.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 2 September 2021.
  2. Action

    Share up-to-date opiate prescribing guidance across Stockport practices.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 2 September 2021.

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

  1. Position

    Existing prescribing safeguards are considered sufficient to ensure safe opiate prescribing across the individual practice and wider Stockport GP community.

    Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 address continued prescription of liquid morphine despite non-adherence to dosage instructions

Wider context from the report

“The inquest heard that Elaine Inns continued to be prescribed a combination of medication including a number of powerful painkillers although it was well understood that she was also using alcohol in significant quantities whilst taking her prescribed medication. The evidence before the court also indicated that she would use the prescribed liquid morphine without clearly following the recommended dosage instructions. She continued to be prescribed it. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Failure to account for significant alcohol use when prescribing powerful painkillers

Wider context from the report

“The inquest heard that Elaine Inns continued to be prescribed a combination of medication including a number of powerful painkillers although it was well understood that she was also using alcohol in significant quantities whilst taking her prescribed medication. The evidence before the court also indicated that she would use the prescribed liquid morphine without clearly following the recommended dosage instructions. She continued to be prescribed it. ”

Is this part of a recurring concern?

Yes — Failure to identify clinically significant medication risks; Unsafe medication prescribing; 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

Work with system colleagues to ensure adherence to best-practice opiate prescribing guidance.

Verbatim wording from the response

“Having reviewed this overall investigation and the circumstances which led to the issue of your Regulation 28 report, I reach the conclusion that the key issue is the prescribing of opiates and I am satisfied that appropriate steps have been taken to ensure the safe prescribing of opiate medication at the individual practice and across the wider Stockport GP community. I will ensure that the most up to date opiate prescribing guidance is shared across our practices and work with colleagues across our system to ensure adherence to best practice guidance.”

Source location

2021-0285-Response-from-Stockport-CCG_Published.pdf
Page 4 · response
Published 2 September 2021

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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

Share up-to-date opiate prescribing guidance across Stockport practices.

Verbatim wording from the response

“Having reviewed this overall investigation and the circumstances which led to the issue of your Regulation 28 report, I reach the conclusion that the key issue is the prescribing of opiates and I am satisfied that appropriate steps have been taken to ensure the safe prescribing of opiate medication at the individual practice and across the wider Stockport GP community. I will ensure that the most up to date opiate prescribing guidance is shared across our practices and work with colleagues across our system to ensure adherence to best practice guidance.”

Source location

2021-0285-Response-from-Stockport-CCG_Published.pdf
Page 4 · response
Published 2 September 2021

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

Existing prescribing safeguards are considered sufficient to ensure safe opiate prescribing across the individual practice and wider Stockport GP community.

Verbatim wording from the response

“Having reviewed this overall investigation and the circumstances which led to the issue of your Regulation 28 report, I reach the conclusion that the key issue is the prescribing of opiates and I am satisfied that appropriate steps have been taken to ensure the safe prescribing of opiate medication at the individual practice and across the wider Stockport GP community. I will ensure that the most up to date opiate prescribing guidance is shared across our practices and work with colleagues across our system to ensure adherence to best practice guidance.”

Source location

2021-0285-Response-from-Stockport-CCG_Published.pdf
Page 4 · response
Published 2 September 2021

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