PFD report

Graham Martin SAFFERY · Prevention of Future Deaths report

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Issued 18 Sep 2019•Bedfordshire and Luton

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
4

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 of the BNF to provide caution and monitoring guidance for simultaneous amitriptyline and oxycodone prescribing
    Part of recurring concern: Inadequate guidance for safe opioid prescribingPart of recurring concern: Incomplete medication safety guidance for prescribers
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Not all opioid–tricyclic combinations should be stopped because low-dose combinations may be clinically appropriate; risks should be reviewed individually.

    Stated by NHS Central East Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 BNF to provide caution and monitoring guidance for simultaneous amitriptyline and oxycodone prescribing

Wider context from the report

“Although other pharmacological guidance such as Medscape Drug Interaction Checker and Stockley’s Interaction Checker recommend the need for both caution and monitoring when prescribing amitriptyline and oxycodone simultaneously, such advice does not appear to be provided by the BNF which is regularly consulted and relied upon by GPs. ”

Is this part of a recurring concern?

Yes — Inadequate guidance for safe opioid prescribing; Incomplete medication safety guidance for prescribers.

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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

Not all opioid–tricyclic combinations should be stopped because low-dose combinations may be clinically appropriate; risks should be reviewed individually.

Verbatim wording from the response

“We are not expecting that all patients identified on a combination of an opioid and tricyclic antidepressant will have their medication stopped, but the risk associated with the level of sedation will be reviewed and action can then be taken as appropriate. The use of low dose opioids with low dose amitriptyline may be clinically appropriate.”

Source location

2019-0301-Response-by-Bedfordshire-CCG
Page 3 · response
Published 5 November 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.4

  1. 1

    Develop and publish a SystmOne search identifying patients prescribed a high-strength opioid and a tricyclic antidepressant.

    Stated by NHS Central East Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 5 November 2019.
  2. 2

    Continue monitoring prescribing data to ensure reviews of patients receiving oxycodone and amitriptyline have taken place.

    Stated by NHS Central East Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2019.
  3. 3

    Share the Queen’s Park Surgery report and its learning with regional and local prescribing stakeholders.

    Stated by NHS Central East Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 5 November 2019.
  4. 4

    Brief prescribing leads on the case and instruct them to use the search and document patient reviews and care plans where appropriate.

    Stated by NHS Central East Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 5 November 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The doubled amitriptyline dose was within the licensed maximum and prescribing guidelines, so the dosing concern was not substantiated.

    Stated by NHS Central East Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 publish a SystmOne search identifying patients prescribed a high-strength opioid and a tricyclic antidepressant.

Verbatim wording from the response

“• The CCGs Locality team have developed and published a SystmOne search to identify any patient, in the GP practices, on a high strength opioid and a tricyclic antidepressant.”

Source location

2019-0301-Response-by-Bedfordshire-CCG
Page 2 · response
Published 5 November 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

Continue monitoring prescribing data to ensure reviews of patients receiving oxycodone and amitriptyline have taken place.

Verbatim wording from the response

“• The NHS National Business Services Authority have published a dashboard to include patient numbers on a combination of oxycodone and amitriptyline and the CCG team will continue to monitor numbers to ensure reviews have taken place.”

Source location

2019-0301-Response-by-Bedfordshire-CCG
Page 2 · response
Published 5 November 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

Share the Queen’s Park Surgery report and its learning with regional and local prescribing stakeholders.

Verbatim wording from the response

“The Head of Medicines Optimisation at the CCG has shared the detailed report from Queen’s Park Surgery with ████████ Controlled Drugs Accountable Officer for the East of England (NHS England) to ensure that the learning is shared across the region.”

Source location

2019-0301-Response-by-Bedfordshire-CCG
Page 2 · response
Published 5 November 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

Brief prescribing leads on the case and instruct them to use the search and document patient reviews and care plans where appropriate.

Verbatim wording from the response

“• All prescribing leads have been briefed on this case at the prescribing leads meetings and asked to run the search and ensure all patients are reviewed and the review is clearly documented in the notes, with the necessary care plan as appropriate.”

Source location

2019-0301-Response-by-Bedfordshire-CCG
Page 2 · response
Published 5 November 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 doubled amitriptyline dose was within the licensed maximum and prescribing guidelines, so the dosing concern was not substantiated.

Verbatim wording from the response

“CCG response: ████████ has submitted a detailed report to the CCG for consideration alongside the practice report. During the consultation (14th June) ████████ noted the dose of the amitriptyline to be 75mg daily. The dose of amitriptyline had been recommended to be doubled by ████████ at East London NHS Foundation Trust (ELFT), our community mental health provider, which we have confirmed verbally with ELFT, but no communication”

Source location

2019-0301-Response-by-Bedfordshire-CCG
Page 1 · response
Published 5 November 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