PFD report

Beverley Shaw · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 10 Jun 2019•Manchester North

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
4

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
20

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 raised4

  1. Failure to communicate clinically significant butane gas use and consumption amount to the GP practice
    Part of recurring concern: Unreliable multi-agency communication procedures
  2. Failure to transfer the full medical records and past medical history to the new substance misuse service
    Part of recurring concern: Failure to reliably transfer medical records between healthcare organisations
  3. Failure to conduct a full review of all prescribed medications
    Part of recurring concern: Inadequate review of long-term medication use
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.16

  1. Action

    Implement a DNA policy requiring discussion of missed appointments and selection of an appropriate patient-contact method.

    Stated by Hopwood House Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
  2. Action

    Provide feedback to the locum doctor about the inadequacy of the medication review.

    Stated by Hopwood House Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
  3. Action

    Use the electronic Butane-misuse code on patients’ problem lists in future.

    Stated by Hopwood House Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The commissioned provider is responsible for resolving transfer of full records when a new provider takes over.

    Stated by Hopwood House Medical PracticeRedirects 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 clinically significant butane gas use and consumption amount to the GP practice

Wider context from the report

“○ There was a lack of communication between Turning Point and the GP practice specifically in respect of Ms Shaw’s use of butane gas. There was no information contained in the evidence before the Court to indicate her GP was aware of the use of butane gas, which was significant (ie 5 cans a day). This was described in evidence by Turning Point as her most significant addiction which was not amenable to treatment with medication. There was one 4 page letter dated the 15th May 2018 from Turning Point to the GP practice, in the summary section this simply recorded, “Uses butane gas daily.” In the section headed “Current Reported Substance Use” there is no mention of butane gas. The remainder of this letter deals with other matters. No information was shared with the GP with regards to the amount of gas being used by Ms Shaw. ”

Is this part of a recurring concern?

Yes — Unreliable multi-agency communication procedures.

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 transfer the full medical records and past medical history to the new substance misuse service

Wider context from the report

“○ The Court heard evidence that following the transition from another provider to Turning Point a decision was taken that all medical records relating to users of the substance misuse service do not need to be carried over to Turning Point. Unlike other medical records ie GP records which go with the patient when they move surgery the new substance misuse service only receives the last 6 months records hence they do not have the full past medical history available. ”

Is this part of a recurring concern?

Yes — Failure to reliably transfer medical records between healthcare organisations.

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 conduct a full review of all prescribed medications

Wider context from the report

“○ A medication review took place in the GP practice in August 208, this only documented a review of her olanzapine medication and the fact that she was in receipt of methadone and using cocaine. There is no evidence that there was a full review of all the medications prescribed to Ms Shaw. When questioned it was accepted in Court it was unclear as to why she was still being prescribed a number of medications. ”

Is this part of a recurring concern?

Yes — Inadequate review of long-term medication use.

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 respond to and action clinical information requests from the substance misuse service

Wider context from the report

“○ There is no record of a response from the GP practice to Turning Point following their letter dated the 15th May 2018. This had a number of requests for actions by the GP including the sharing of any blood results (LFT, FC and U&E), together with information confirming whether there was any blood disorders of drugs which may interact with methadone. There was no evidence that this information was shared or actioned. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable integration of substance misuse services into patient care; Unreliable inter-agency information sharing for coordinated care.

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

Implement a DNA policy requiring discussion of missed appointments and selection of an appropriate patient-contact method.

Verbatim wording from the response

“Since the inquest we have as a practice reflected on Beverley’s death and have discussed what we could have done differently to prevent her death. We noticed that in her records she had many failed appointments (DNAs) and possibly not fully engaged with clinicians about her health. In April 2019 we put together a DNA policy. The policy outlines that patients who DNA shall be discussed in the practice meeting and a suitable method of contacting the patient should be sought. On reflection with this patient if we had done this, Miss Shaw could have been referred to the Focus Care worker linked to our practice and she would have had a home visit assessment. From this we may have been made aware of the extent of her Butane abuse and this could have been communicated to the clinicians and Turning Point.”

Source location

2019-0191-Response-by-Hopwood-House-Medical-Practice
Page 1 · response
Published 23 August 2019

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

Provide feedback to the locum doctor about the inadequacy of the medication review.

Verbatim wording from the response

“The last medication review was done by one of our regular locum doctors who has been working at the practice for the last 3 years. From the practice meeting we concluded that the medication review was sub-adequate and the lead GP of the practice will feed this back to him. However, given the time limits and pressures in primary care, and the inconsistencies of CCG employed pharmacists, the practice has made a decision to employ a clinical pharmacist do complicated medication reviews and help with the workload. Despite this, as highlighted already by the letter from the 15th May 2018 sent by ████████ (Consultant Psychiatrist), they have a clear accurate record of Miss Shaw’s medication and any drug interactions that may have been overlooked by the practice, perhaps should have been double checked then.”

Source location

2019-0191-Response-by-Hopwood-House-Medical-Practice
Page 2 · response
Published 23 August 2019

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

Use the electronic Butane-misuse code on patients’ problem lists in future.

Verbatim wording from the response

“We also found the electronic code “Misuse of Butane EMISNQM197”. That we will use in future to code this on the Problem List.”

Source location

2019-0191-Response-by-Hopwood-House-Medical-Practice
Page 2 · response
Published 23 August 2019

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

Maintain heightened vigilance in communication, correspondence and medication reviews, particularly for sedatives, chronic pain medication, methadone and substance misuse.

Verbatim wording from the response

“I note that there were several opportunities where she could have had some of her chronic pain medication reduced. However these were missed. Again this will be avoided in future when a clinical pharmacist is employed by the practice and can go through complicated medication reviews. The GPs in the practice are aware of this as a significant event and will be mindful of patients on sedatives, chronic pain medication with methadone and substance abuse.”

Source location

2019-0191-Response-by-Hopwood-House-Medical-Practice
Page 3 · response
Published 23 August 2019

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

Employ a clinical pharmacist to undertake complicated medication reviews and support practice workload.

Verbatim wording from the response

“The last medication review was done by one of our regular locum doctors who has been working at the practice for the last 3 years. From the practice meeting we concluded that the medication review was sub-adequate and the lead GP of the practice will feed this back to him. However, given the time limits and pressures in primary care, and the inconsistencies of CCG employed pharmacists, the practice has made a decision to employ a clinical pharmacist do complicated medication reviews and help with the workload. Despite this, as highlighted already by the letter from the 15th May 2018 sent by ████████ (Consultant Psychiatrist), they have a clear accurate record of Miss Shaw’s medication and any drug interactions that may have been overlooked by the practice, perhaps should have been double checked then.”

Source location

2019-0191-Response-by-Hopwood-House-Medical-Practice
Page 2 · response
Published 23 August 2019

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

Communicate the butane-misuse EMIS code to all Oldham GP practices as a review lesson.

Verbatim wording from the response

“In respect of the butane gas use, the appropriate electronic code has been identified to flag misuse of butane on the EMIS system. This will be communicated to all practices as part of the lessons learned from this review to ensure that all Oldham GP practices are aware of this code.”

Source location

2019-0191-Response-by-Oldham-NHS-CCG
Page 1 · response
Published 23 August 2019

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

Identify the EMIS electronic code for flagging butane misuse.

Verbatim wording from the response

“In respect of the butane gas use, the appropriate electronic code has been identified to flag misuse of butane on the EMIS system. This will be communicated to all practices as part of the lessons learned from this review to ensure that all Oldham GP practices are aware of this code.”

Source location

2019-0191-Response-by-Oldham-NHS-CCG
Page 1 · response
Published 23 August 2019

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

Address identified locum GP competency issues through appropriate channels.

Verbatim wording from the response

“From a system perspective, there is clear learning in reviewing the medication and prescribing issues identified in Ms Shaw’s situation. This has highlighted some locum GP competency issues within the practice that have been addressed through the appropriate channels. The learning that has arisen from reviewing this lady’s care as a significant event has emphasised the importance of careful consideration of methadone use and subsequent or potential prescribed medication interactions. There is the facility for medications prescribed external to the practice (i.e. hospital or externally commissioned service such as Turning Point) to be entered into the EMIS system and therefore prompt alerts. This will also be highlighted to all practices and supported through the clinical pharma in-reach into all clusters.”

Source location

2019-0191-Response-by-Oldham-NHS-CCG
Page 2 · response
Published 23 August 2019

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

Promote wider uptake of Focussed Care across Oldham practices to support substance-use-related care.

Verbatim wording from the response

“The events surrounding Ms Shaw’s death highlight the requirement for effective and up to date ‘Did Not Attend’ policies to be followed in Primary Care and to initiate discussion in practice meetings to ensure holistic information is shared and reviewed by the team in a manner which supports clinicians to make decisions based on the full facts and influencing factors. Such discussions can trigger communication back to secondary providers such as Turning Point to clarify and/or share information. The presence of Focussed Care within a number of Oldham practices has been seen to support such instances where substance use influences existing co-morbidities and as a CCG we are promoting wider uptake of this across the Oldham footprint.”

Source location

2019-0191-Response-by-Oldham-NHS-CCG
Page 2 · response
Published 23 August 2019

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

Highlight recording externally prescribed medicines in EMIS, and associated interaction alerts, to all practices through clinical-pharmacist cluster support.

Verbatim wording from the response

“From a system perspective, there is clear learning in reviewing the medication and prescribing issues identified in Ms Shaw’s situation. This has highlighted some locum GP competency issues within the practice that have been addressed through the appropriate channels. The learning that has arisen from reviewing this lady’s care as a significant event has emphasised the importance of careful consideration of methadone use and subsequent or potential prescribed medication interactions. There is the facility for medications prescribed external to the practice (i.e. hospital or externally commissioned service such as Turning Point) to be entered into the EMIS system and therefore prompt alerts. This will also be highlighted to all practices and supported through the clinical pharma in-reach into all clusters.”

Source location

2019-0191-Response-by-Oldham-NHS-CCG
Page 2 · response
Published 23 August 2019

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

Change prescriber templates used to review clients across community substance misuse services.

Verbatim wording from the response

“This review has highlighted the key processes that we needed to change in order to improve effective communication and reduce the risk of future recurrence. Those processes are the template used by prescribers to review clients, the frequency of communication with GPs, the way that communication is recorded on our electronic client records system and the processes for audit of the frequency of that communication.”

Source location

2019-0191-Response-by-Turning-Point
Page 1 · response
Published 23 August 2019

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

Complete a wide-ranging review of GP communication across all community substance misuse services.

Verbatim wording from the response

“Whilst we recognise that the clinician had written to the GP, we accept that there is more that we could do to improve this communication, not only in this tragic case but also more broadly across our substance misuse services. Therefore, we have undertaken a wide ranging review of GP communication across all our community substance misuse services, not just in Rochdale and Oldham. That review has been led by our Senior Management Team, including our senior clinical team, and our Risk and Assurance department.”

Source location

2019-0191-Response-by-Turning-Point
Page 1 · response
Published 23 August 2019

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

Change the frequency of communication with GPs across community substance misuse services.

Verbatim wording from the response

“This review has highlighted the key processes that we needed to change in order to improve effective communication and reduce the risk of future recurrence. Those processes are the template used by prescribers to review clients, the frequency of communication with GPs, the way that communication is recorded on our electronic client records system and the processes for audit of the frequency of that communication.”

Source location

2019-0191-Response-by-Turning-Point
Page 1 · response
Published 23 August 2019

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 and improve follow-up systems for requests to GPs for information.

Verbatim wording from the response

“We also reviewed our systems for following up requests to GPs for information and the way in which we transfer client data at the beginning and at the end of contracts.”

Source location

2019-0191-Response-by-Turning-Point
Page 1 · response
Published 23 August 2019

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

Improve processes for transferring client data at the beginning and end of contracts.

Verbatim wording from the response

“We also reviewed our systems for following up requests to GPs for information and the way in which we transfer client data at the beginning and at the end of contracts.”

Source location

2019-0191-Response-by-Turning-Point
Page 1 · response
Published 23 August 2019

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

Improve recording of GP communications in the electronic client records system.

Verbatim wording from the response

“This review has highlighted the key processes that we needed to change in order to improve effective communication and reduce the risk of future recurrence. Those processes are the template used by prescribers to review clients, the frequency of communication with GPs, the way that communication is recorded on our electronic client records system and the processes for audit of the frequency of that communication.”

Source location

2019-0191-Response-by-Turning-Point
Page 1 · response
Published 23 August 2019

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 commissioned provider is responsible for resolving transfer of full records when a new provider takes over.

Verbatim wording from the response

“Records This is related to the commissioned provider and I hope that they can resolve this issue with the transfer of full records with a new provider.”

Source location

2019-0191-Response-by-Hopwood-House-Medical-Practice
Page 3 · response
Published 23 August 2019

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

A joint learning meeting with Turning Point would occur only if Oldham CCG supported it.

Verbatim wording from the response

“The practice would also, if supported through Oldham CCG have a meeting with Turning Point separately as a learning event to see what further changes we can both make to make sure miscommunications are avoided in the future”

Source location

2019-0191-Response-by-Hopwood-House-Medical-Practice
Page 4 · response
Published 23 August 2019

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

Clinical Pharmacists cannot reconcile every patient’s medications because current resources do not permit it; entering external prescriptions is considered safer.

Verbatim wording from the response

“From a system perspective, there is clear learning in reviewing the medication and prescribing issues identified in Ms Shaw’s situation. This has highlighted some locum GP competency issues within the practice that have been addressed through the appropriate channels. The learning that has arisen from reviewing this lady’s care as a significant event has emphasised the importance of careful consideration of methadone use and subsequent or potential prescribed medication interactions. There is the facility for medications prescribed external to the practice (i.e. hospital or externally commissioned service such as Turning Point) to be entered into the EMIS system and therefore prompt alerts. This will also be highlighted to all practices and supported through the clinical pharma in-reach into all clusters.”

Source location

2019-0191-Response-by-Oldham-NHS-CCG
Page 2 · response
Published 23 August 2019

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.4

  1. 1

    Re-communicate central-office access to Focussed Care workers for practices without a directly linked worker.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
  2. 2

    Coordinate a learning event with Hopwood House Medical Centre and Oldham Turning Point to agree actions for improving working relationships.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 August 2019.
  3. 3

    Establish compliance monitoring for the new standards through routine management audits.

    Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
  4. 4

    Change audit processes for monitoring the frequency of GP communications.

    Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.

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

Re-communicate central-office access to Focussed Care workers for practices without a directly linked worker.

Verbatim wording from the response

“Practices that do not have a focussed Care worker directly linked to their practice do have access through the central office and this will be re-communicated as part of the lessons learned from this situation.”

Source location

2019-0191-Response-by-Oldham-NHS-CCG
Page 2 · response
Published 23 August 2019

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

Coordinate a learning event with Hopwood House Medical Centre and Oldham Turning Point to agree actions for improving working relationships.

Verbatim wording from the response

“The CCG are co-ordinating a learning event with Hopwood House Medical Centre and the Oldham Turning Point team to facilitate a group reflection and agreed actions on how we can improve working relationships. The learning from this will also form the basis of a learning event that Turning Point are undertaking across the borough with those GP practices signing up to shared care arrangements.”

Source location

2019-0191-Response-by-Oldham-NHS-CCG
Page 2 · response
Published 23 August 2019

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

Establish compliance monitoring for the new standards through routine management audits.

Verbatim wording from the response

“I am pleased to say that we have made all those improvements not only in Rochdale and Oldham but also in all our community substance misuse services across the country and made the changes within our planned timescales. We have also agreed how we will monitor compliance with those new standards as part of our routine management audits.”

Source location

2019-0191-Response-by-Turning-Point
Page 1 · response
Published 23 August 2019

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

Change audit processes for monitoring the frequency of GP communications.

Verbatim wording from the response

“This review has highlighted the key processes that we needed to change in order to improve effective communication and reduce the risk of future recurrence. Those processes are the template used by prescribers to review clients, the frequency of communication with GPs, the way that communication is recorded on our electronic client records system and the processes for audit of the frequency of that communication.”

Source location

2019-0191-Response-by-Turning-Point
Page 1 · response
Published 23 August 2019

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