PFD report

Joanna Clare Alice Flynn · Prevention of Future Deaths report

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Issued 14 Nov 2019•Essex

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
4

Named on the report

Responses found
3

Of 4 recipients

Stated actions
21

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. Inadequate training and education for general practitioners and GP practices in care for patients dependent on prescribed opiates
  2. Lack of specialised assistance and referral agencies for general practitioners supporting patients dependent on prescribed opiates
    Part of recurring concern: Unreliable specialist support for reducing and withdrawing from prescribed opioids
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.8

  1. Action

    Request NICE guidance on safe prescribing of dependence-associated medicines and careful withdrawal management.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 December 2019.
  2. Action

    Distribute and promote PrescQIPP webinars and e-learning resources to prescribers.

    Stated by NHS Mid Essex Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 9 December 2019.
  3. Action

    Develop and mobilise a commissioned Management of Prescribed Opioid Dependence Local Enhanced Service providing multidisciplinary support, weaning plans and primary-care education.

    Stated by NHS Mid Essex Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 9 December 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    Postgraduate GP training curricula are set by royal colleges and faculties, with GMC approval of curricula and assessment systems.

    Stated by Department of Health and Social CareRedirects 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

Inadequate training and education for general practitioners and GP practices in care for patients dependent on prescribed opiates

Wider context from the report

“The General Practitioner who gave evidence told the court that there was a lacuna in the healthcare provided for patients such as the deceased in terms of giving assistance for weaning off addictive prescription drugs such as opiates. It was clear that General Practitioner’s require highly specialised assistance in order to help such patients and agencies within the healthcare system to which to refer them. This was all lacking in this particular sad set of circumstances. The court was informed about a proposed pilot scheme – a substance misuse Locally Enhanced Service for people with dependence to prescribed opiates. There was no assurance that this had commenced or indeed yet been funded. I would like an assurance that this hopeful initiative has got off the ground and indeed I would like to have information about any other initiatives to endeavour to address this dreadful problem. I would also like to hear what strides have been taken to improve training and education for general practitioners and GP practices in this worrying area of care. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Lack of specialised assistance and referral agencies for general practitioners supporting patients dependent on prescribed opiates

Wider context from the report

“The General Practitioner who gave evidence told the court that there was a lacuna in the healthcare provided for patients such as the deceased in terms of giving assistance for weaning off addictive prescription drugs such as opiates. It was clear that General Practitioner’s require highly specialised assistance in order to help such patients and agencies within the healthcare system to which to refer them. This was all lacking in this particular sad set of circumstances. The court was informed about a proposed pilot scheme – a substance misuse Locally Enhanced Service for people with dependence to prescribed opiates. There was no assurance that this had commenced or indeed yet been funded. I would like an assurance that this hopeful initiative has got off the ground and indeed I would like to have information about any other initiatives to endeavour to address this dreadful problem. I would also like to hear what strides have been taken to improve training and education for general practitioners and GP practices in this worrying area of care. ”

Is this part of a recurring concern?

Yes — Unreliable specialist support for reducing and withdrawing from prescribed opioids.

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

Request NICE guidance on safe prescribing of dependence-associated medicines and careful withdrawal management.

Verbatim wording from the response

“In addition, the Department asked the National Institute for Health and Care Excellence (NICE) to develop guidance on the safe prescribing of drugs associated with dependence”

Source location

2019-0369-Response-from-the-Department-of-Health-and-Social-Care
Page 1 · response
Published 9 December 2019

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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

Distribute and promote PrescQIPP webinars and e-learning resources to prescribers.

Verbatim wording from the response

“4) Signposting to webinars and e-learning”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 5 · response
Published 9 December 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

Develop and mobilise a commissioned Management of Prescribed Opioid Dependence Local Enhanced Service providing multidisciplinary support, weaning plans and primary-care education.

Verbatim wording from the response

“• Working closely with our local substance misuse service provider, mental health trust and local pain consultants to develop a Management of Prescribed Opioid Dependence Local Enhanced Service, more details of which are provided below.”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 2 · response
Published 9 December 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

Configure Scriptswitch to flag high-dose opioid risks, provide specialist contact details and link to the opioid resource pack.

Verbatim wording from the response

“2) Inclusion of pop-up information message on Scriptswitch®”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 4 · response
Published 9 December 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

Deliver an Opioids and Safe Prescribing session at the March Time to Learn event.

Verbatim wording from the response

“A session on Opioids and Safe Prescribing is also planned at the CCG’s Time to Learn event in March. These are quarterly events organised by the CCG for all surgeries in mid Essex, with paid clinical cover to allow GPs to attend in normal working hours, where practices can take part in collective learning and share best practice.”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 6 · response
Published 9 December 2019

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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 learning resources supporting clinicians to identify, assess and respond to medicine dependence and withdrawal.

Verbatim wording from the response

“• Providing a range of learning resources to help clinicians develop their knowledge of, and competence to identify, assess and respond to, dependence or withdrawal associated with some medicines and the support needs of people experiencing problems with withdrawal or dependence.”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 2 · response
Published 9 December 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

Continue supporting primary care through additional funding, staff and organisational development for vulnerable, high-risk patients.

Verbatim wording from the response

“It is important to acknowledge the current pressures on primary care. NHSE continues to support primary care with additional funding, staff and organisational development to ensure time and resources are available to care for these vulnerable patients who are potentially high risk and will often need input from the most experienced staff.”

Source location

2019-0369-Response-from-NHS-England-and-NHS-Improvement
Page 2 · response
Published 9 December 2019

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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

Ensure appropriate expertise and resources are universally available to support patients dependent on prescribed medicines and reduce associated morbidity and mortality.

Verbatim wording from the response

“NHSE is committed to fully understanding contributing factors to this serious problem and ensuring that all appropriate expertise and resources are universally available to support these patients and reduce the likelihood of future associated morbidity and mortality.”

Source location

2019-0369-Response-from-NHS-England-and-NHS-Improvement
Page 2 · response
Published 9 December 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

Postgraduate GP training curricula are set by royal colleges and faculties, with GMC approval of curricula and assessment systems.

Verbatim wording from the response

“The curricula for postgraduate specialty training, which includes training for GPs, is set by individual royal colleges and faculties, and the GMC approves curricula and assessment systems for each training programme. Training curricula for doctors emphasise the skills and approaches that a doctor must develop in order to ensure accurate and timely diagnoses and treatment plans for their patients.”

Source location

2019-0369-Response-from-the-Department-of-Health-and-Social-Care
Page 3 · response
Published 9 December 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

Specialised services for people dependent on prescription medicines are the responsibility of local commissioners.

Verbatim wording from the response

“Finally, the provision of specialised services to support people dependent on prescription medicines is a matter for local commissioners. I am aware that the Mid-Essex Clinical Commissioning Group (CCG) has responded to your report explaining the services that are in place locally to support patients and GPs. This includes the new Management of Prescribed Opioid Dependence Locally Enhanced Service (referenced in your report), that is anticipated to be in place from 1 April 2020. I am advised that other measures are being taken locally to promote better prescribing and reduce the amount of opioids being prescribed.”

Source location

2019-0369-Response-from-the-Department-of-Health-and-Social-Care
Page 4 · response
Published 9 December 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

Undergraduate GP education curricula are set by individual medical schools and must meet standards monitored by the GMC.

Verbatim wording from the response

“In relation to the education and training of GPs on supporting patients dependent on prescribed medicines, it is for individual medical schools to sets their own undergraduate medical curriculum. These have to meet the standards set by the General Medical Council (GMC), which monitors and checks to make sure that the standards are maintained.”

Source location

2019-0369-Response-from-the-Department-of-Health-and-Social-Care
Page 3 · response
Published 9 December 2019

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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

Extending the existing service to support prescribed-opioid dependence was not possible, so an alternative service model was developed.

Verbatim wording from the response

“To address this gap in services, Mid Essex CCG agreed in November 2018 to fund a service to support GPs and patients dealing with this issue. Initially the CCG was hoping to work with Essex County Council to extend the existing STaRS service to include patients dependent upon prescribed opioids. Unfortunately after an extended dialogue with the Council and also directly with Essex Partnership University Trust (the provider of STaRS) it became apparent that this would not be possible and so the CCG has been working with local GPs and pharmacists to develop an alternative service model.”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 3 · response
Published 9 December 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

Commissioning substance misuse services is a public health responsibility of local authorities.

Verbatim wording from the response

“The ‘pilot’ scheme referred to by ████████ at the request is a local service that the CCG has been seeking to introduce to support patients with a dependency upon prescribed medicines. Whilst the commissioning of substance misuse services is one of the public health responsibilities of Local Authorities, the Essex Specialist Treatment and Recovery Service (STaRS) commissioned by Essex County Council only provides advice and support to help GPs manage patients dependent on prescribed opioids. STaRS will only see people for adjunctive problematic use of prescribed and/or over-the-counter medications, if their primary problematic substances are alcohol or illicit drugs.”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 3 · response
Published 9 December 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

Specialist support beyond general practice is usually delivered through services commissioned by clinical commissioning groups.

Verbatim wording from the response

“Many of these patients will require input beyond ‘conventional’ general practice, usually via a CCG commissioned service that could take the form of a Locally Commissioned Service (in effect an enhanced GP service) or through a contract with an alternative provider, usually across a CCG footprint.”

Source location

2019-0369-Response-from-NHS-England-and-NHS-Improvement
Page 2 · response
Published 9 December 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.13

  1. 1

    Request a review of NHS overprescribing, concurrent problematic medication use and helping patients stop unnecessary repeat prescriptions.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 December 2019.
  2. 2

    Work with healthcare regulatory partners to improve the safety of medicines supplied online.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 9 December 2019.
  3. 3

    Commission an evidence review of the scale, distribution and causes of prescription drug dependence and potential responses.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 9 December 2019.
  4. 4

    Analyse practice-level controlled-drug prescribing data and monitor progress in opioid deprescribing.

    Stated by NHS Mid Essex Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 9 December 2019.
  5. 5

    Include opioid-reduction requirements in the Medicines Optimisation Local Enhanced Scheme for participating practices.

    Stated by NHS Mid Essex Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 9 December 2019.
  6. 6

    Continue discussing long-term opioid safety through the Medicines Optimisation Committee and seeking GP support for new guidance.

    Stated by NHS Mid Essex Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 9 December 2019.
  7. 7

    Make opioid safety and withdrawal resources, including patient information leaflets, publicly available on the CCG website.

    Stated by NHS Mid Essex Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 9 December 2019.
  8. 8

    Identify 174 patients prescribed oxycodone and amitriptyline and alert their GPs to conduct early medication reviews.

    Stated by NHS Mid Essex Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 9 December 2019.
  9. 9

    Revise and publish joint pain guidance incorporating opioid deprescribing, social prescribing and non-pharmacological alternatives.

    Stated by NHS Mid Essex Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 9 December 2019.
  10. 10

    Add a prescribing-system reminder prompting GPs to ask about over-the-counter codeine products before prescribing codeine.

    Stated by NHS Mid Essex Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 9 December 2019.
  11. 11

    Publish an open patient letter encouraging self-reduction of low-dose opioids.

    Stated by NHS Mid Essex Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 9 December 2019.
  12. 12

    Develop a full understanding of factors contributing to dependence on prescribed medicines and associated serious harm.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 9 December 2019.
  13. 13

    Establish a review group examining dependence on and withdrawal from prescribed medicines, including opiate prescribing.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 December 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

Request a review of NHS overprescribing, concurrent problematic medication use and helping patients stop unnecessary repeat prescriptions.

Verbatim wording from the response

“The report acknowledged that work to tackle this issue has already started or is planned. For example, England’s Chief Pharmaceutical Officer, Dr Keith Ridge, was asked by the Secretary of State for Health and Social Care, Matt Hancock, to review overprescribing in the NHS, problematic use of multiple medications concurrently, and how to help patients come off repeat prescriptions they no longer need.”

Source location

2019-0369-Response-from-the-Department-of-Health-and-Social-Care
Page 1 · response
Published 9 December 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

Work with healthcare regulatory partners to improve the safety of medicines supplied online.

Verbatim wording from the response

“In the UK, strict legal requirements apply to the retail sale and supply of medicines for example, Prescription Only (POM) and Pharmacy (P) medicines may only be legally sold or supplied to the public through registered pharmacy premises, by or under the supervision of a pharmacist and POMs may only be sold or supplied in response to a prescription from an authorised healthcare professional (such as a doctor, dentist, or certain trained nurses and pharmacists). Legal controls apply without distinction to medicines sold online and much is being done by healthcare regulators to protect the public and improve the safety of medicines online. The Department is working closely with healthcare regulatory partners to support this work.”

Source location

2019-0369-Response-from-the-Department-of-Health-and-Social-Care
Page 3 · response
Published 9 December 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

Commission an evidence review of the scale, distribution and causes of prescription drug dependence and potential responses.

Verbatim wording from the response

“In 2017, Public Health England (PHE) was commissioned to conduct an evidence review to identify the scale, distribution and causes of prescription drug dependence, and what might be done to address it. PHE’s report of the review was published in September 2019¹.”

Source location

2019-0369-Response-from-the-Department-of-Health-and-Social-Care
Page 1 · response
Published 9 December 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

Analyse practice-level controlled-drug prescribing data and monitor progress in opioid deprescribing.

Verbatim wording from the response

“Actions now being undertaken to implement the recommendations from the PHE report include:”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 2 · response
Published 9 December 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

Include opioid-reduction requirements in the Medicines Optimisation Local Enhanced Scheme for participating practices.

Verbatim wording from the response

“1) Inclusion of opioid reduction within the Medicines Optimisation Local Enhanced Scheme”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 4 · response
Published 9 December 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

Continue discussing long-term opioid safety through the Medicines Optimisation Committee and seeking GP support for new guidance.

Verbatim wording from the response

“6) Engagement with GPs”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 6 · response
Published 9 December 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

Make opioid safety and withdrawal resources, including patient information leaflets, publicly available on the CCG website.

Verbatim wording from the response

“• Building on previously developed resources to support safe management and withdrawal of opioids and making these publicly available on the CCG website, including patient information leaflets on the safe use of opioids.”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 2 · response
Published 9 December 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 174 patients prescribed oxycodone and amitriptyline and alert their GPs to conduct early medication reviews.

Verbatim wording from the response

“In response to this letter, we have used Eclipse Live to identify 174 patients in mid Essex on oxycodone and amitriptyline and have sent an alert message to each patient’s registered GP encouraging an early medication review. We have also added onto Scriptswitch® (a prescribing support system which runs on GP practices’ clinical systems) a reminder to GPs to ask about over the counter codeine or codeine-containing products when they are considering prescribing any codeine.”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 3 · response
Published 9 December 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

Revise and publish joint pain guidance incorporating opioid deprescribing, social prescribing and non-pharmacological alternatives.

Verbatim wording from the response

“5) Revised Pain Guidance”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 5 · response
Published 9 December 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

Add a prescribing-system reminder prompting GPs to ask about over-the-counter codeine products before prescribing codeine.

Verbatim wording from the response

“In response to this letter, we have used Eclipse Live to identify 174 patients in mid Essex on oxycodone and amitriptyline and have sent an alert message to each patient’s registered GP encouraging an early medication review. We have also added onto Scriptswitch® (a prescribing support system which runs on GP practices’ clinical systems) a reminder to GPs to ask about over the counter codeine or codeine-containing products when they are considering prescribing any codeine.”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 3 · response
Published 9 December 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

Publish an open patient letter encouraging self-reduction of low-dose opioids.

Verbatim wording from the response

“3) Open letter to patients encouraging self-reduction of low dose opioids”

Source location

2019-0369-Response-by-Mid-Essex-CCG
Page 5 · response
Published 9 December 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

Develop a full understanding of factors contributing to dependence on prescribed medicines and associated serious harm.

Verbatim wording from the response

“NHSE is committed to fully understanding contributing factors to this serious problem and ensuring that all appropriate expertise and resources are universally available to support these patients and reduce the likelihood of future associated morbidity and mortality.”

Source location

2019-0369-Response-from-NHS-England-and-NHS-Improvement
Page 2 · response
Published 9 December 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 a review group examining dependence on and withdrawal from prescribed medicines, including opiate prescribing.

Verbatim wording from the response

“A review group has been established in response to the recent Public Health England review of dependence on, and withdrawal from, prescribed medicines. The group has senior NHS E/I input including Keith Ridge (Chief Pharmaceutical Officer) and Nikki Kanani (Medical Director for Primary Care) as well as other system stakeholders. It will include opiate prescribing. I do not have details of the case other than as outlined in your Regulation 28 report but hopefully the following”

Source location

2019-0369-Response-from-NHS-England-and-NHS-Improvement
Page 1 · response
Published 9 December 2019

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