PFD report

Jerome Alexander Peat · Prevention of Future Deaths report

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Issued 4 Feb 2021•Avon

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
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

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Concerns and recipient responses

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Concerns raised1

  1. Failure of the EMIS computer medical record to alert the medical centre to prior GP registration
    Part of recurring concern: Unreliable clinical safety-alert systems
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 of the EMIS computer medical record to alert the medical centre to prior GP registration

Wider context from the report

“The EMIS computer medical record on 4.11.19 failed to alert ████████ at Long Furlong Medical Centre that Mr. Peat had already registered with the GP at the Student Medical Centre, as a result of which there was inadvertent duplication of his morphine prescription on 4.11.19 and 5.11.19 and Mr. Peat was prescribed significantly more morphine than was intended. He subsequently died from an overdose of prescribed morphine. ”

Is this part of a recurring concern?

Yes — Unreliable clinical safety-alert systems.

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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