John Ioannou · Prevention of Future Deaths report

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Issued 6 Jan 2015•North London

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

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 raised1

  1. Lack of guidance for GPs when patients are not collecting medication required to treat their mental health conditions
    Part of recurring concern: Failure to provide timely clinical follow-up after medication prescribing

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

  1. Department of Health and Social Care

    Existing NICE guidance addresses poor adherence by requiring re-referral to secondary care and development of shared risk management plans.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. Department of Health and Social Care

    Monitoring whether patients collect or take medication would be difficult because of scale, data-sharing, consent and treatment-refusal constraints.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  3. Department of Health and Social Care

    NHS England is responsible for considering feasible action on monitoring medication non-collection and providing an update.

    Redirects 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

Lack of guidance for GPs when patients are not collecting medication required to treat their mental health conditions

Wider context from the report

“There was no guidance for GPs where the patient is not collecting medication required to treat their mental health condition (s). ”

Is this part of a recurring concern?

Yes — Failure to provide timely clinical follow-up after medication prescribing.

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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

Existing NICE guidance addresses poor adherence by requiring re-referral to secondary care and development of shared risk management plans.

Verbatim wording from the response

“The National Institute for Health and Clinical Excellence (NICE) has published guidelines which set out best practice for the treatment of Bipolar Disorder. This includes guidance that where a patient is being treated solely in a primary care setting (e.g. by a GP) the patient should be re-referred to secondary care if treatment adherence is poor. The guidelines also state that in managing crisis, risk and challenging behaviour in adults with Bipolar Disorder secondary care providers should develop a risk management plan and share it with the patient’s GP.”

Source location

2015-0012-Response-by-Department-of-Health
Page 2 · response
Published 6 January 2015

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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

Monitoring whether patients collect or take medication would be difficult because of scale, data-sharing, consent and treatment-refusal constraints.

Verbatim wording from the response

“However, there is a larger question of how a GP would become aware that a patient had stopped taking medication, particularly if medication is prescribed on a repeat prescription which allows patients to order re-fills without seeing their GPs. Over one billion prescription items are issued by general practices each year and it would therefore be a large and complex task to monitor individual patients. Aside from the practicalities, there would be issues of appropriate data sharing, patient consent, and the right to refuse treatment. NHS England advises that it has sought the advice of its Primary Care Patient Safety Expert Group and Mental Health Patient Safety Expert Group on what action might feasibly be taken in this area. NHS England will be able to provide an update on these discussions by the end of April 2015.”

Source location

2015-0012-Response-by-Department-of-Health
Page 2 · response
Published 6 January 2015

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

NHS England is responsible for considering feasible action on monitoring medication non-collection and providing an update.

Verbatim wording from the response

“However, there is a larger question of how a GP would become aware that a patient had stopped taking medication, particularly if medication is prescribed on a repeat prescription which allows patients to order re-fills without seeing their GPs. Over one billion prescription items are issued by general practices each year and it would therefore be a large and complex task to monitor individual patients. Aside from the practicalities, there would be issues of appropriate data sharing, patient consent, and the right to refuse treatment. NHS England advises that it has sought the advice of its Primary Care Patient Safety Expert Group and Mental Health Patient Safety Expert Group on what action might feasibly be taken in this area. NHS England will be able to provide an update on these discussions by the end of April 2015.”

Source location

2015-0012-Response-by-Department-of-Health
Page 2 · response
Published 6 January 2015

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