PFD report

Andrew Peter McCall · Prevention of Future Deaths report

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Issued 1 Jul 2019•Stoke-on-Trent and North Staffordshire

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

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to independently verify patients’ concurrent opiate replacement therapy and prescribing organisation
    Part of recurring concern: Unreliable communication of critical medication information to GPsPart of recurring concern: Unreliable inter-agency information sharing for coordinated care
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.2

  1. Action

    Write to Staffordshire GP practices about the inquest risks, considering other agencies' opiate prescribing, and alerting the clinic when patients are registered elsewhere.

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

    Contact the service lead and request reviews of GP-data collection, verification, and reliable information sharing with registered GPs.

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The Local Authority, rather than NHS England or the Clinical Commissioning Group, commissions these substance misuse services.

    Stated by NHS EnglandRedirects 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

Failure to independently verify patients’ concurrent opiate replacement therapy and prescribing organisation

Wider context from the report

“The evidence revealed a clear pattern of “medication seeking behaviour” with his GP to obtain additional amounts of Pregabalin. The evidence also showed that his GP was not aware that he was on a current Methadone script. The “One Recovery” clinic operated a system which was dependent upon the service user declaring which GP practice they were registered with. This was not checked or verified independently and therefore concern must exist that the GP may be unaware that a patient is on an opiate replacement regime, prescribed by another organisation, and may therefore prescribe medications which may not be suitable and which may potentially be harmful. It is suggested that, where patients are prescribed medication as part of “opiate replacement therapy”, GPs have the means to check the details and the organisation providing such a service. This puts in place a more robust system to ensure that the current GP is fully aware of the treatment programme. ”

Is this part of a recurring concern?

Yes — Unreliable communication of critical medication information to GPs; Unreliable inter-agency information sharing for coordinated care.

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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

Write to Staffordshire GP practices about the inquest risks, considering other agencies' opiate prescribing, and alerting the clinic when patients are registered elsewhere.

Verbatim wording from the response

“Write to all GP practices within Staffordshire: - making them aware of the inquest findings, and the risks this highlights; - reminding them of the importance of considering whether other agencies might be prescribing opiate replacements; and - asking them to alert the clinic directly if they receive information relating to a patient not registered at the practice (so the correct practice can be identified quickly).”

Source location

2019-0228-Response-by-NHS-England
Page 2 · response
Published 13 September 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

Contact the service lead and request reviews of GP-data collection, verification, and reliable information sharing with registered GPs.

Verbatim wording from the response

“Dr Kenneth Deacon, Medical Director for System Improvement and Professional Standards (Midlands) will:”

Source location

2019-0228-Response-by-NHS-England
Page 2 · response
Published 13 September 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

The Local Authority, rather than NHS England or the Clinical Commissioning Group, commissions these substance misuse services.

Verbatim wording from the response

“In this case the service is provided by One Recovery Clinic, in conjunction with North Staffordshire Combined Healthcare NHS Trust. The lead provider is Addiction Dependency Solution. Substance misuse services are commissioned by the Local Authority, not NHS England or the Clinical Commissioning Group.”

Source location

2019-0228-Response-by-NHS-England
Page 1 · response
Published 13 September 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

NHS England is neither commissioner nor regulator of these substance misuse services and has no direct responsibility for them.

Verbatim wording from the response

“Although NHS England is neither the commissioner or regulator of these services, and have no direct responsibility for them, we recognise the importance of the concerns you have raised, and are taking the following action:”

Source location

2019-0228-Response-by-NHS-England
Page 2 · response
Published 13 September 2019

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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.1

  1. 1

    Share the communication with the Local Authority so it can monitor the service through its commissioning responsibilities.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 13 September 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

Share the communication with the Local Authority so it can monitor the service through its commissioning responsibilities.

Verbatim wording from the response

“Share the above communication with the Local Authority, to allow them to monitor as part of their commissioning responsibility for this service.”

Source location

2019-0228-Response-by-NHS-England
Page 2 · response
Published 13 September 2019

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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