PFD report

Tanya Rosemary Marion Oladejo · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 22 Apr 2014•West London

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
8

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to communicate medication changes between the GP practice and responsible clinician
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable communication of patient-care information between clinical staffPart of recurring concern: Unreliable implementation of medication changes
  2. Failure to ensure medication directions and labels correspond to the prescribed use
    Part of recurring concern: Unreliable medication dosage verification and communication
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.5

  1. Action

    Review processes for recording medications across different healthcare sectors.

    Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
  2. Action

    Discuss with CNWL and Hillingdon Hospitals pharmacy leads the possibility of developing a standard cross-sector medication letter or form.

    Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
  3. Action

    Have practice pharmacists review and improve medicines-reconciliation processes in GP practices.

    Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The CCG should respond to concerns about inadequate communication by the GP with the Trust clinician.

    Stated by Central and North West London NHS Foundation TrustRedirects 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 communicate medication changes between the GP practice and responsible clinician

Wider context from the report

“(1) The responsible clinician had made adjustments to the prescribed medication regime including allowing the GP to vary the amount of sertraline according to the patient’s presentation. (2) The GP, in fact, also on occasion titrated the amount of amitriptyline prescribed according to the patient’s presentation. (3) The responsible clinician was not made aware of the unilateral titration of amitriptyline so, accordingly, was unaware that a drug she had (in discussion with the patient) prescribed to be used as a sleeping draft was, in fact, being prescribed clearly labelled to be taken in the mornings. (4) In this case, there was a worrying lack of adequate communication between the GP practice and the responsible clinician about medication prescribed to assist in controlling Tanya’s condition ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable communication of patient-care information between clinical staff; Unreliable implementation of medication changes.

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 medication directions and labels correspond to the prescribed use

Wider context from the report

“(1) The responsible clinician had made adjustments to the prescribed medication regime including allowing the GP to vary the amount of sertraline according to the patient’s presentation. (2) The GP, in fact, also on occasion titrated the amount of amitriptyline prescribed according to the patient’s presentation. (3) The responsible clinician was not made aware of the unilateral titration of amitriptyline so, accordingly, was unaware that a drug she had (in discussion with the patient) prescribed to be used as a sleeping draft was, in fact, being prescribed clearly labelled to be taken in the mornings. (4) In this case, there was a worrying lack of adequate communication between the GP practice and the responsible clinician about medication prescribed to assist in controlling Tanya’s condition ”

Is this part of a recurring concern?

Yes — Unreliable medication dosage verification and communication.

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

Review processes for recording medications across different healthcare sectors.

Verbatim wording from the response

“1. Review the current processes for recording medications in the different sectors by August 2014”

Source location

2014-0203-Response-by-Hillingdon-Commissioning-Group
Page 3 · response
Published 22 April 2014

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

Discuss with CNWL and Hillingdon Hospitals pharmacy leads the possibility of developing a standard cross-sector medication letter or form.

Verbatim wording from the response

“3. Discuss with the Pharmacy Leads in CNWL and the Hillingdon Hospitals Trust the possibility of developing one standard letter or form for use across all sectors in July 2014”

Source location

2014-0203-Response-by-Hillingdon-Commissioning-Group
Page 3 · response
Published 22 April 2014

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

Have practice pharmacists review and improve medicines-reconciliation processes in GP practices.

Verbatim wording from the response

“4. Ensure our practice pharmacists review and improve medicines reconciliation processes in practices starting in July 2014 and on-going thereafter.”

Source location

2014-0203-Response-by-Hillingdon-Commissioning-Group
Page 3 · response
Published 22 April 2014

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

Review processes for communicating medication information between healthcare sectors, including medication changes and treatment follow-up.

Verbatim wording from the response

“On receiving the Initial Management Report a view was sought from the HCCG mental health commissioner, the clinical leads for NWL Mental Health Programme Board, and Hillingdon CCG medicines management lead on 19th May. It was agreed to explore the time frame and process for notification of any change of medication and follow-up sessions of treatment between GPs and CNWL lead clinician. A response from the HCCG Head of Medicines Management was received on 27th May 2014.”

Source location

2014-0203-Response-by-Hillingdon-Commissioning-Group
Page 2 · response
Published 22 April 2014

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

Circulate an anonymised Clinical Risk Alert highlighting communication lessons from the case to staff across the organisation.

Verbatim wording from the response

“I must advise you that in our view the issue of particular concern in this case was one that related to inadequate communication by the GP to our clinician and it is appropriate for the CCG to respond to you on that particular point. We are satisfied that in this case our communication systems were effective. However, as an organisation we are always keen to learn from any incidents that occur and we felt it would be helpful to ensure that staff across our organisation are reminded of the importance of good communication. One of the means we have for disseminating such lessons is a Clinical Risk Alert. We will be circulating an alert in the next few weeks which will include reference to this case (in an anonymised form). I should be happy to forward a copy to you if you would find that of interest.”

Source location

2014-0203-Response-by-Central-North-West-London-NHS-Trust
Page 1 · response
Published 22 April 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 CCG should respond to concerns about inadequate communication by the GP with the Trust clinician.

Verbatim wording from the response

“I must advise you that in our view the issue of particular concern in this case was one that related to inadequate communication by the GP to our clinician and it is appropriate for the CCG to respond to you on that particular point. We are satisfied that in this case our communication systems were effective. However, as an organisation we are always keen to learn from any incidents that occur and we felt it would be helpful to ensure that staff across our organisation are reminded of the importance of good communication. One of the means we have for disseminating such lessons is a Clinical Risk Alert. We will be circulating an alert in the next few weeks which will include reference to this case (in an anonymised form). I should be happy to forward a copy to you if you would find that of interest.”

Source location

2014-0203-Response-by-Central-North-West-London-NHS-Trust
Page 1 · response
Published 22 April 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 Trust considered its communication systems effective in this case and did not identify a need to change them.

Verbatim wording from the response

“I must advise you that in our view the issue of particular concern in this case was one that related to inadequate communication by the GP to our clinician and it is appropriate for the CCG to respond to you on that particular point. We are satisfied that in this case our communication systems were effective. However, as an organisation we are always keen to learn from any incidents that occur and we felt it would be helpful to ensure that staff across our organisation are reminded of the importance of good communication. One of the means we have for disseminating such lessons is a Clinical Risk Alert. We will be circulating an alert in the next few weeks which will include reference to this case (in an anonymised form). I should be happy to forward a copy to you if you would find that of interest.”

Source location

2014-0203-Response-by-Central-North-West-London-NHS-Trust
Page 1 · response
Published 22 April 2014

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.3

  1. 1

    Communicate the medicines-reconciliation learning to Hillingdon GPs through the weekly GP newsletter.

    Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
  2. 2

    Share medicines-reconciliation recommendations with the Hillingdon, Brent and Harrow Medicines Management Teams and the CCG prescribing lead.

    Stated by NHS Hillingdon Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 22 April 2014.
  3. 3

    Present the case’s communication lessons to the Mental Health Partnership Board for learning purposes.

    Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.

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

Communicate the medicines-reconciliation learning to Hillingdon GPs through the weekly GP newsletter.

Verbatim wording from the response

“May 28th 2013 these recommendations were shared with the Medicines Management Teams in Hillingdon, and subsequently in Brent and Harrow CCGs. BHH (Hillingdon, Brent and Harrow) have a shared quality and clinical governance structure. This learning has subsequently been shared with the CCG governing body lead for prescribing, and will be communicated with Hillingdon GPs via the weekly GP newsletter in the week commencing 16th June.”

Source location

2014-0203-Response-by-Hillingdon-Commissioning-Group
Page 3 · response
Published 22 April 2014

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 medicines-reconciliation recommendations with the Hillingdon, Brent and Harrow Medicines Management Teams and the CCG prescribing lead.

Verbatim wording from the response

“May 28th 2013 these recommendations were shared with the Medicines Management Teams in Hillingdon, and subsequently in Brent and Harrow CCGs. BHH (Hillingdon, Brent and Harrow) have a shared quality and clinical governance structure. This learning has subsequently been shared with the CCG governing body lead for prescribing, and will be communicated with Hillingdon GPs via the weekly GP newsletter in the week commencing 16th June.”

Source location

2014-0203-Response-by-Hillingdon-Commissioning-Group
Page 3 · response
Published 22 April 2014

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 the case’s communication lessons to the Mental Health Partnership Board for learning purposes.

Verbatim wording from the response

“I will also be taking this for learning purposes to the Mental Health Partnership Board, which comprises the 8 CCGs and 2 mental health trusts in North West London, in order to highlight the importance of the communication lessons from this case.”

Source location

2014-0203-Response-by-Central-North-West-London-NHS-Trust
Page 1 · response
Published 22 April 2014

Open published response
Back to top

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