David Lee Gomer TRAVERS · Prevention of Future Deaths report

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Issued 22 Jun 2018•Plymouth, Torbay and South Devon

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
10

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised1

  1. Failure to prevent persons from accessing multiple prescriptions across different GP surgeries

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. Devon Local Medical Committee (Devon LMC and NHS Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG

    Provide education and training on drug-seeking behaviour, prescribing risks and support strategies to clinicians and relevant students and trainees.

  2. Devon Local Medical Committee (Devon LMC and NHS Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG

    Review the Patient Alert Scheme and investigate the feasibility of a regularly updated, electronically distributed alert list.

  3. Devon Local Medical Committee (Devon LMC and NHS Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG

    Produce and disseminate guidance on identifying and managing drug-seeking behaviour to GP practices and relevant healthcare providers.

  4. Devon Local Medical Committee (Devon LMC and NHS Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG

    Issue local guidance on checks for suspicious emergency-supply and temporary-resident prescription requests.

  5. Devon Local Medical Committee (Devon LMC and NHS Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG

    Convene a system-wide meeting to address concerns about multiple prescription access and drug diversion.

  6. Devon Local Medical Committee (Devon LMC and NHS Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG

    Negotiate with the prison provider to improve electronic provision of discharge health information to primary care.

  7. Devon Local Medical Committee (Devon LMC and NHS Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG

    Communicate and promote the national Special Allocation Scheme to all GP practices in NEW Devon.

  8. Devon Local Medical Committee (Devon LMC and NHS Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG

    Review the patient alert paperwork and system for usefulness, information-sharing appropriateness, effectiveness and ease of use.

  9. Devon Local Medical Committee (Devon LMC and NHS Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG

    Provide practices with an up-to-date Special Allocation Scheme patient list and require patient records to be annotated with VP.

  10. Devon Local Medical Committee (Devon LMC and NHS Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG

    Communicate the recommendations for national action through NHS England.

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

  1. Devon Local Medical Committee (Devon LMC and NHS Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG

    NHS Digital must evaluate the feasibility of recommended NHS spine and clinical-system changes because it is responsible for NHS spine IT systems.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. Devon Local Medical Committee (Devon LMC and NHS Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG

    NHS England and NHS Audit South West must agree improvements to the Patient Alert Scheme because they manage it.

    Redirects 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 prevent persons from accessing multiple prescriptions across different GP surgeries

Wider context from the report

“Evidence from several witnesses indicated that Mr Travers was able to access multiple prescriptions for drugs by moving around Plymouth and the surrounding area and presenting to different GP surgeries as requiring drugs. Evidence also indicated that Mr Travers would sell or barter prescription drugs to obtain illicit drugs. There are apparently measures in place to raise alerts across GP surgeries and NHS Trusts to exchange information about persons who may be attempting to exploit the issuing of drug prescriptions, however given the above evidence, I am concerned that it is nevertheless still too easy for persons to access multiple prescriptions. This presents a risk to those who are able to obtain and take excessive amounts of prescription drugs and a route by which prescription drugs can enter an illegal drugs market ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Provide education and training on drug-seeking behaviour, prescribing risks and support strategies to clinicians and relevant students and trainees.

Verbatim wording from the response

“v. Education and training to include the themes in iii) above. This to be provided at confederation meetings, to final year medical / dental / non-medical prescriber students, registrars and newly qualified GPs.”

Source location

2018-0188-Response-by-Northern-Eastern-and-Western-Devon-CCG
Page 7 · response
Published 9 July 2018

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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 Patient Alert Scheme and investigate the feasibility of a regularly updated, electronically distributed alert list.

Verbatim wording from the response

“i. Review of the Patient Alert Scheme. We recognise that the current scheme has some deficiencies so we recommend the following changes:”

Source location

2018-0188-Response-by-Northern-Eastern-and-Western-Devon-CCG
Page 5 · response
Published 9 July 2018

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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

Produce and disseminate guidance on identifying and managing drug-seeking behaviour to GP practices and relevant healthcare providers.

Verbatim wording from the response

“iii. Guidance on dealing with drug seeking behaviour to be produced and disseminated to GP practices and others (some elements of this will also be applicable to hospitals, community pharmacies, MIUs, walk in centres and dental practices. These sites should be encouraged to adopt relevant parts of the guidance). The guidance should cover the following broad themes:”

Source location

2018-0188-Response-by-Northern-Eastern-and-Western-Devon-CCG
Page 6 · response
Published 9 July 2018

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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

Issue local guidance on checks for suspicious emergency-supply and temporary-resident prescription requests.

Verbatim wording from the response

“iii. Patients away from home who need medical care or prescription supplies can be prescribed up to 14 days’ medicines as an emergency supply (ES) or can register with a practice as a temporary resident (TR) if they are in the area for longer than 24 hours but less than 3 months. Mr Travers managed to obtain medication from four different Cornish practices within a week in June 2017 either as ES or TR supplies. ES can be made without proof of identity or to patients without a fixed abode. Homeless patients are entitled to register with a GP using a temporary address which may be a friend's address or a day centre. The practice may also use the practice address to register them. We are therefore planning to issue local guidance about checks to be made if there is a degree of suspicion about these requests (see section 2) b)).”

Source location

2018-0188-Response-by-Northern-Eastern-and-Western-Devon-CCG
Page 4 · response
Published 9 July 2018

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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

Convene a system-wide meeting to address concerns about multiple prescription access and drug diversion.

Verbatim wording from the response

“c. System wide meeting planned. It became clear from the outset that the concerns you raised were multi-faceted and that we would need the input of many different organisations to fully inform the process. We therefore convened a meeting of representatives from the following organisations or teams which took place on 7th August 2018:”

Source location

2018-0188-Response-by-Northern-Eastern-and-Western-Devon-CCG
Page 2 · response
Published 9 July 2018

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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

Negotiate with the prison provider to improve electronic provision of discharge health information to primary care.

Verbatim wording from the response

“f. The letter from Livewell to Safer Systems included two points, the first related directly to the concerns you have raised; however, the second point highlighted the lack of information provided by the Prison discharging Mr Travers in March 2017. There has been a further DRD this year in which a lack of salient information from the prison on discharge was implicated as a potential contributing factor. NEW Devon CCG is in negotiation with the prison provider Care UK, to improve the provision of health information to primary care for people released from prison. This will preferably be by electronic means as the prison service uses the same computer software as the majority of GP practices in Devon. This action has been added to the action tracker (see section 2) to ensure it is completed.”

Source location

2018-0188-Response-by-Northern-Eastern-and-Western-Devon-CCG
Page 3 · response
Published 9 July 2018

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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

Communicate and promote the national Special Allocation Scheme to all GP practices in NEW Devon.

Verbatim wording from the response

“ii. The Special Allocation Scheme (SAS)”

Source location

2018-0188-Response-by-Northern-Eastern-and-Western-Devon-CCG
Page 6 · response
Published 9 July 2018

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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 patient alert paperwork and system for usefulness, information-sharing appropriateness, effectiveness and ease of use.

Verbatim wording from the response

“d. Reflection by NEW Devon CCG MOT on the patient alert paperwork and system, including the usefulness, appropriateness of information for sharing, effectiveness and ease of use, resulting in the following action:”

Source location

2018-0188-Response-by-Northern-Eastern-and-Western-Devon-CCG
Page 3 · response
Published 9 July 2018

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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

Provide practices with an up-to-date Special Allocation Scheme patient list and require patient records to be annotated with VP.

Verbatim wording from the response

“• We propose that an up to date list of patients on the scheme is provided to all practices and that the patient record is annotated with VP.”

Source location

2018-0188-Response-by-Northern-Eastern-and-Western-Devon-CCG
Page 6 · response
Published 9 July 2018

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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

Communicate the recommendations for national action through NHS England.

Verbatim wording from the response

“We will communicate our recommendations for national action through NHS England and would value your support in promoting them nationally also.”

Source location

2018-0188-Response-by-Northern-Eastern-and-Western-Devon-CCG
Page 7 · response
Published 9 July 2018

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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

NHS Digital must evaluate the feasibility of recommended NHS spine and clinical-system changes because it is responsible for NHS spine IT systems.

Verbatim wording from the response

“i. NHS Digital is responsible for the NHS spine IT systems. Most of the recommendations in this section will need to be directed to NHS Digital for evaluation of feasibility.”

Source location

2018-0188-Response-by-Northern-Eastern-and-Western-Devon-CCG
Page 4 · response
Published 9 July 2018

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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

NHS England and NHS Audit South West must agree improvements to the Patient Alert Scheme because they manage it.

Verbatim wording from the response

“i. Review of the Patient Alert Scheme. We recognise that the current scheme has some deficiencies so we recommend the following changes:”

Source location

2018-0188-Response-by-Northern-Eastern-and-Western-Devon-CCG
Page 5 · response
Published 9 July 2018

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