PFD report

Amy Anne June Ganner · Prevention of Future Deaths report

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Issued 24 Jun 2021•Manchester West

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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

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Concerns raised1

  1. Risk of opioid toxicity following unpredictable loss of tolerance
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.1

  1. Action

    Discuss with the MHRA how to improve access to opioid safety information leaflets.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.

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

Risk of opioid toxicity following unpredictable loss of tolerance

Wider context from the report

“The deceased had suffered with chronic pain from complex medical conditions for several years. Her medication included Tramadol capsules; Zomorph modified release capsules and morphine sulphate oral solution all of which were opioid drugs associated with central nervous and respiratory depressant effects. Their individual effects would be enhanced when taken in combination and these depressant effects would be exacerbated by her use of the other drugs appropriately prescribed for her. As for all opiate cases the toxicological significance of the morphine concentration will depend upon the degree of tolerance possessed by the deceased. In this case as the opiate based medication was prescribed for her and being used regularly she would be expected to have a degree of tolerance. However it is known and was asserted in evidence that tolerances can be quickly lost, in the event of a period of abstinence; that the diminution of tolerance varies from person to person and is extremely difficult to predict. Whilst the deceased was intelligent and had a clear understanding of the risks, benefits and role of her medication both her general practitioner who gave evidence and I believe that it would be extremely helpful if the Department of Health was to support the production of a leaflet in both electronic and paper formats dealing with the concept of ‘tolerance’ and emphasising the serious risk of toxicity which would be available to all whom are prescribed opiate based medication ”

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

Discuss with the MHRA how to improve access to opioid safety information leaflets.

Verbatim wording from the response

“Furthermore, I will speak to the MHRA about how to improve access to their information leaflets, to ensure this information is as widely available as possible.”

Source location

2021-0218-Response-from-Department-of-Health-and-Social-Care_Published
Page 2 · response
Published 28 June 2021

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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.2

  1. 1

    Commission and publish an evidence review on the scale, distribution and causes of prescription drug dependence.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 28 June 2021.
  2. 2

    Develop a Quality Improvement Module for general practice on preventing prescription drug dependency.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 28 June 2021.

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 and publish an evidence review on the scale, distribution and causes of prescription drug dependence.

Verbatim wording from the response

“In 2017, the Government asked Public Health England (PHE) 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 2019⁶, providing evidence for dependence on, and withdrawal from, prescribed medicines, with the aim of making sure that local healthcare systems build awareness and support to enhance clinician and patient decision making.”

Source location

2021-0218-Response-from-Department-of-Health-and-Social-Care_Published
Page 3 · response
Published 28 June 2021

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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

Develop a Quality Improvement Module for general practice on preventing prescription drug dependency.

Verbatim wording from the response

“Finally, since October 2020, Primary Care Networks of GPs have been required to identify and prioritise patients, including patients using potentially addictive pain management medication, who would benefit from a structured medication review. You may also wish to note that for the February 2020 update to the GP contract agreement 2020/21 to 2023/24, a Quality Improvement Module in the Quality and Outcomes Framework for general practice on preventing prescription drug dependency is in development.”

Source location

2021-0218-Response-from-Department-of-Health-and-Social-Care_Published
Page 3 · response
Published 28 June 2021

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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