Chloe Elizabeth Burgess · Prevention of Future Deaths report

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Issued 4 Mar 2025•Hampshire, Portsmouth and Southampton

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
2

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
1

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

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

Concerns raised2

  1. Failure of prescribing software to trigger alerts for the interaction between amitriptyline, paroxetine and ivabradine
    Part of recurring concern: Unreliable clinical safety-alert systems
  2. Lack of prescriber understanding of the interaction between ivabradine, amitriptyline and paroxetine
    Part of recurring concern: Unsafe medication prescribing

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Royal College of Physicians

    Discuss the case at the Patient Safety Committee and Joint Medicines Safety Working Group to determine whether further action is needed.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Royal College of Physicians

    Prescribers are responsible for understanding medicine interactions and applying appropriate caution or monitoring rather than relying solely on software alerts.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. Royal College of Physicians

    Prescribing software alerts are determined by independent commercial providers, which choose the reference materials informing alert content.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  3. National Institute for Health and Care Excellence

    BNF publishers, rather than NICE, are best placed to address concerns about drug interactions.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  4. National Institute for Health and Care Excellence

    NICE cannot comment on drug-interaction concerns because BNF content responsibility remains with its publishers.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant 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 of prescribing software to trigger alerts for the interaction between amitriptyline, paroxetine and ivabradine

Wider context from the report

“The inquest heard evidence that the potential dangers of the combination of amitriptyline, paroxetine and ivabradine is not widely appreciated and does not trigger an alert on the prescribing software used in primary care or by pharmacists. The potential dangers related to a failure to metabolise amitriptyline which can, incrementally, lead to toxicity. I am also concerned that those prescribing ivabradine should have a full understanding of the potential interaction with amitriptyline and paroxetine. ”

Is this part of a recurring concern?

Yes — Unreliable clinical safety-alert systems.

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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

Lack of prescriber understanding of the interaction between ivabradine, amitriptyline and paroxetine

Wider context from the report

“The inquest heard evidence that the potential dangers of the combination of amitriptyline, paroxetine and ivabradine is not widely appreciated and does not trigger an alert on the prescribing software used in primary care or by pharmacists. The potential dangers related to a failure to metabolise amitriptyline which can, incrementally, lead to toxicity. I am also concerned that those prescribing ivabradine should have a full understanding of the potential interaction with amitriptyline and paroxetine. ”

Is this part of a recurring concern?

Yes — 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

Discuss the case at the Patient Safety Committee and Joint Medicines Safety Working Group to determine whether further action is needed.

Verbatim wording from the response

“The Royal College of Physicians works closely with the Royal Pharmaceutical Society, the British Pharmacological Society and NHS England Chief Pharmacists. We will discuss this case at our next Patient Safety Committee and Joint Medicines Safety Working Group, to explore whether further action should be taken informed by this case.”

Source location

Response from Royal College of Physicians
Page 2 · response
Published 7 March 2025

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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

Prescribers are responsible for understanding medicine interactions and applying appropriate caution or monitoring rather than relying solely on software alerts.

Verbatim wording from the response

“It is the role of all prescribers to understand the overarching mechanisms of action of medicines they may prescribe, and where similar actions occur by more than one medicine, or might exacerbate pathology in individual patients, particular caution or monitoring should be instituted. It is important that they do not rely on prescribing software, but use recognised reference materials.”

Source location

Response from Royal College of Physicians
Page 2 · response
Published 7 March 2025

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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

Prescribing software alerts are determined by independent commercial providers, which choose the reference materials informing alert content.

Verbatim wording from the response

“The Royal Pharmaceutical Society, as joint publishers of the BNF, have advised that pharmacokinetic (drug metabolism) interactions are included within the BNF, but that all theoretical compound effects of combinations of medications through their mode of action cannot be included. Furthermore, prescribing software for primary care and pharmacies is provided by independent commercial organisations, who will choose which reference materials they use to inform alerts. This software and its application is currently not regulated.”

Source location

Response from Royal College of Physicians
Page 2 · response
Published 7 March 2025

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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

BNF publishers, rather than NICE, are best placed to address concerns about drug interactions.

Verbatim wording from the response

“We have reflected on the circumstances surrounding Chloe’s death, and the concerns raised in your report regarding drug interactions. The British National Formulary (BNF) provides key information on the selection, prescribing, dispensing and administration of medicines and we believe that they would be best placed to address your concerns.”

Source location

Response from National Institute for Health and Care Excellence
Page 1 · response
Published 7 March 2025

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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

NICE cannot comment on drug-interaction concerns because BNF content responsibility remains with its publishers.

Verbatim wording from the response

“The BNF is a joint publication of the BMJ Group and Pharmaceutical Press, the publishing division of the Royal Pharmaceutical Society. While we make the BNF available on the NICE website, responsibility for the content remains with the publishers and therefore NICE cannot comment on the concerns you have raised.”

Source location

Response from National Institute for Health and Care Excellence
Page 1 · response
Published 7 March 2025

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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