PFD report

Steven Terence Allen · Prevention of Future Deaths report

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Issued 2 Jun 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 adequately challenge additional replacement prescriptions
    Part of recurring concern: Inadequate safeguards against misuse of medicines with abuse potential
  2. Failure to account for addiction, self-harm and poor substance use when prescribing medication
    Part of recurring concern: Failure to identify clinically significant medication risksPart of recurring concern: Inadequate safeguards against misuse of medicines with abuse potentialPart 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.2

  1. Action

    Continue discussions with Primary Care Network leads to explore Stockport Integrated Pharmacy Service support for optimising medication reviews.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 4 June 2021.
  2. Action

    Remind Stockport GPs about available opioid-prescribing resources and how to seek support through the next pharmacy newsletter.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 4 June 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 guidance and clinician adherence are considered sufficient because the incident is regarded as isolated.

    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 adequately challenge additional replacement prescriptions

Wider context from the report

“The inquest heard that he had a chaotic lifestyle and a history of drug addiction. He was in significant pain and was prescribed medication to manage his pain including oxycodone. He was prescribed this and additional medications although there was a history of addiction, self-harm and poor use of prescribed and illicit substances. Prescribing of these medications was done through telephone consultations due to Covid 19 and on occasion additional replacement prescriptions were given with little challenge. ”

Is this part of a recurring concern?

Yes — Inadequate safeguards against misuse of medicines with abuse potential.

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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 addiction, self-harm and poor substance use when prescribing medication

Wider context from the report

“The inquest heard that he had a chaotic lifestyle and a history of drug addiction. He was in significant pain and was prescribed medication to manage his pain including oxycodone. He was prescribed this and additional medications although there was a history of addiction, self-harm and poor use of prescribed and illicit substances. Prescribing of these medications was done through telephone consultations due to Covid 19 and on occasion additional replacement prescriptions were given with little challenge. ”

Is this part of a recurring concern?

Yes — Failure to identify clinically significant medication risks; Inadequate safeguards against misuse of medicines with abuse potential; 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

Continue discussions with Primary Care Network leads to explore Stockport Integrated Pharmacy Service support for optimising medication reviews.

Verbatim wording from the response

“• The Medicines Management Team is currently in discussion with the Primary Care Network (PCN) Leads to explore how the Stockport Integrated Pharmacy Service (SIPS) can support GP Practices in optimising medication reviews for this patient cohort.”

Source location

2021-0190-Response-from-Stockport-Clinical-Commissioning-Group-Redacted
Page 2 · response
Published 4 June 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

Remind Stockport GPs about available opioid-prescribing resources and how to seek support through the next pharmacy newsletter.

Verbatim wording from the response

“Greater Manchester Medicines Management Group (GMMMG) Opioid Prescribing for Chronic Pain: Resource Pack”

Source location

2021-0190-Response-from-Stockport-Clinical-Commissioning-Group-Redacted
Page 2 · response
Published 4 June 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 guidance and clinician adherence are considered sufficient because the incident is regarded as isolated.

Verbatim wording from the response

“The Practice take on board the comments included within the Regulation 28 Report and have undertaken a review of this case and looked at their processes for the management of prescribing for patients in this vulnerable cohort. The practice are satisfied that this was an isolated case and that all clinicians do adhere to guidance in relation to informed prescribing and support of this patient group.”

Source location

2021-0190-Response-from-Stockport-Clinical-Commissioning-Group-Redacted
Page 1 · response
Published 4 June 2021

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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