PFD report

Anita Mandalia · Prevention of Future Deaths report

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Issued 9 Jul 2021•East 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.

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Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
0

Of 2 recipients

Stated actions
0

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 raised4

  1. Failure to re-refer patients to secondary mental health services when mental health concerns arise
    Part of recurring concern: Unreliable mental health referral pathways
  2. Failure to maintain medication supplies within the maximum 7-day limit
    Part of recurring concern: Medication quantity controls failing to prevent unsafe access to excessive amounts
  3. Failure to limit prescribing of the medication to the recommended duration
    Part of recurring concern: Unsafe medication prescribing
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 re-refer patients to secondary mental health services when mental health concerns arise

Wider context from the report

“2. Despite having received instructions within a discharge summary from a secondary mental health trust in August 2020 that required the surgery to re-refer Mrs Mandalia if concerns arose regarding her mental health, when issues were raised in October and December 2020 to the surgery no referral was made. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

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 maintain medication supplies within the maximum 7-day limit

Wider context from the report

“3. In June 2020 the surgery introduced measures to mitigate the risk of overdose presented by Mrs Mandalia which required medication to be dispensed in a dosette box containing a maximum 7-day supply of medications. However, on 6th January 2021 Mrs Mandalia was prescribed ████████████████████ for pain which allowed her access to an excess of a ████████ ”

Is this part of a recurring concern?

Yes — Medication quantity controls failing to prevent unsafe access to excessive amounts.

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 limit prescribing of the medication to the recommended duration

Wider context from the report

“1. Mrs Mandalia had been prescribed ████████ NICE guidance and BNF guidance stipulated that this medication ought not to be prescribed for longer than ████████ Mrs Mandalia had received that prescription far longer than the recommended period. The GP surgery had not checked the appropriateness of that prescription. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

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 check the appropriateness of medication prescriptions

Wider context from the report

“1. Mrs Mandalia had been prescribed ████████ NICE guidance and BNF guidance stipulated that this medication ought not to be prescribed for longer than ████████ Mrs Mandalia had received that prescription far longer than the recommended period. The GP surgery had not checked the appropriateness of that prescription. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

Open source report
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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