PFD report

Michelle Jeffries · Prevention of Future Deaths report

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Issued 22 Nov 2021•Manchester South

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

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 raised2

  1. Lack of local guidance mandating referral to a pain specialist
  2. Lack of local guidance on safe GP oversight of high-dose multiple analgesic prescribing in the community
    Part of recurring concern: Inconsistent and unclear prescribing guidance
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.7

  1. Action

    Review Trafford’s repeat-prescribing guidance, with completion scheduled by 31 March 2022.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 November 2021.
  2. Action

    Ask Greater Manchester CCGs to report through the Quality Board on reducing overprescribing, including analgesia, and supporting implementation of DHSC guidance.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 23 November 2021.
  3. Action

    Provide high-risk medication review support through Medicines Optimisation processes and practice-based pharmacists conducting structured medication reviews.

    Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 23 November 2021.

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

  1. Position

    No specific pain-management referral pathway mandates specialist referral; commissioned services are available when GPs consider referral necessary using clinical judgment.

    Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 local guidance mandating referral to a pain specialist

Wider context from the report

“It is a matter of concern that there is an absence of local guidance as to: 1. The circumstances in which GPs can safely oversee the prescription of multiple analgesics at high doses in the community, attempting to reduce reliance on such medication as indicated; and 2. When referral to a pain specialist is mandated. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 local guidance on safe GP oversight of high-dose multiple analgesic prescribing in the community

Wider context from the report

“It is a matter of concern that there is an absence of local guidance as to: 1. The circumstances in which GPs can safely oversee the prescription of multiple analgesics at high doses in the community, attempting to reduce reliance on such medication as indicated; and 2. When referral to a pain specialist is mandated. ”

Is this part of a recurring concern?

Yes — Inconsistent and unclear prescribing guidance.

Open source report

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

Review Trafford’s repeat-prescribing guidance, with completion scheduled by 31 March 2022.

Verbatim wording from the response

“Pain management and NICE guidance have previously been discussed at Trafford local GP Education sessions, held quarterly. Please see documents attached below for further information on the Trafford CCG local guidance on Repeat Prescribing as well the National Institute for Clinical Excellence (NICE) guidance in relation to assessing and managing chronic pain in the over 16’s. The Repeat Prescribing guidance is currently under review and will be complete by 31st March 2022.”

Source location

Response from NHS Greater Manchester
Page 2 · response
Published 23 November 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

Ask Greater Manchester CCGs to report through the Quality Board on reducing overprescribing, including analgesia, and supporting implementation of DHSC guidance.

Verbatim wording from the response

“4. CCGs across Greater Manchester will be asked to provide through Quality Board, a report on how they are reducing overprescribing, including analgesia and support the implementation of “Department of Health and Social Care (DHSC) guidance; Good For You, Good For Us, Good for Everybody - A plan to reduce overprescribing to make patient care better and safer, support the NHS, and reduce carbon emissions.””

Source location

Response from NHS Greater Manchester
Page 3 · response
Published 23 November 2021

Open published response

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

Provide high-risk medication review support through Medicines Optimisation processes and practice-based pharmacists conducting structured medication reviews.

Verbatim wording from the response

“Point 1 – the circumstances in which GP’s can safely oversee the prescription of multiple analgesics in high doses in the community, attempting to reduce reliance on such medications as indicated. The Trafford CCG Medicines Optimisation team support prescribers with many aspects of prescribing including repeat prescribing to ensure robust and safe processes for managing patients repeat medication are in place. Included as part of this are systems for reviewing patients on “high risk” medication, which supports prescribers to ensure that patients on these medicines have regular medication reviews, including blood and physical healthcare monitoring. All practices in Trafford now have a practice based pharmacist working with them and as part of their work they undertake structured medication reviews.”

Source location

Response from NHS Greater Manchester
Page 1 · response
Published 23 November 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

Prioritise patients taking high doses or multiple analgesics for structured medication review through collaboration between medicines optimisation and practice-based teams.

Verbatim wording from the response

“All practices in Trafford now have a practice based pharmacist working with them and as part of their work they undertake structured medication reviews. The CCG Medicines Optimisation Team and practice based teams have been working together to prioritise patients requiring a medication review, with patients on high doses or multiple analgesia being highlighted.”

Source location

Response from NHS Trafford Clinical Commissioning Group
Page 2 · response
Published 23 November 2021

Open published response

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

Provide every Trafford practice with a practice-based pharmacist to undertake structured medication reviews.

Verbatim wording from the response

“All practices in Trafford now have a practice based pharmacist working with them and as part of their work they undertake structured medication reviews. The CCG Medicines Optimisation Team and practice based teams have been working together to prioritise patients requiring a medication review, with patients on high doses or multiple analgesia being highlighted.”

Source location

Response from NHS Trafford Clinical Commissioning Group
Page 2 · response
Published 23 November 2021

Open published response

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

Complete the review of Trafford’s repeat-prescribing guidance by 31 March 2022.

Verbatim wording from the response

“Pain management and NICE guidance have previously been a topic at our local GP Education sessions, held quarterly. Please see documents attached below for further information on the Trafford CCG local guidance on Repeat Prescribing as well the National Institute for Clinical Excellence (NICE) guidance in relation to assessing and managing chronic pain in the over 16’s. The Repeat Prescribing guidance is currently under review and will be complete by 31st March 2022.”

Source location

Response from NHS Trafford Clinical Commissioning Group
Page 2 · response
Published 23 November 2021

Open published response

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

Disseminate the case’s prescribing risks, clinical guidance and available chronic-pain resources to Trafford primary-care staff through the Practice Briefing.

Verbatim wording from the response

“Fortunately the culture in pain management is changing with patients being offered non-pharmacological help and support, in preference, to manage their long term condition rather than medicines to try to “kill the pain”. This report gives us a real example to use in reminding all GPs in Trafford about those risks, what clinicians should be considering in terms of guidance and the resources available to support clinicians in the management of patients with chronic pain. We have therefore included this in our “Practice Briefing”; an email update which is sent out to over 400 Primary Care staff in Trafford twice a week. The information in the briefing also includes a link to the guidance documents we have shared with you above.”

Source location

Response from NHS Trafford Clinical Commissioning Group
Page 3 · response
Published 23 November 2021

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

No specific pain-management referral pathway mandates specialist referral; commissioned services are available when GPs consider referral necessary using clinical judgment.

Verbatim wording from the response

“Point 2 - when referral to a pain specialist is mandated. In terms of when to refer patients to pain specialists, there is no specific pain management pathway that offers GPs guidance on when exactly to refer to a pain specialist. However, in Trafford, there is a commissioned Musculoskeletal (MSK) service available to patients as well as the Manchester Pain Service should any Trafford GP, based on their own clinical judgement, decide a referral is necessary.”

Source location

Response from NHS Greater Manchester
Page 2 · response
Published 23 November 2021

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

Individual GPs decide, using clinical judgment, whether referral to a pain specialist is necessary; no specific pathway mandates referral.

Verbatim wording from the response

“In terms of when to refer patients to pain specialists, there isn’t a specific pain management pathway that offers GP’s guidance on when exactly to refer to a pain specialist. However, in Trafford, there is a commissioned Musculoskeletal (MSK) service available to patients as well as the Manchester Pain Service should any Trafford GP, based on their own clinical judgement, decide a referral is necessary.”

Source location

Response from NHS Trafford Clinical Commissioning Group
Page 2 · response
Published 23 November 2021

Open published response

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.5

  1. 1

    Present and share case learning with the Greater Manchester Quality Board and its participating commissioners, regulators, Healthwatch and NICE representatives.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 23 November 2021.
  2. 2

    Discuss pain-management and NICE guidance through quarterly Trafford local GP education sessions.

    Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 23 November 2021.
  3. 3

    Monitor key learning points and recommendations to ensure they become embedded in practice.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 23 November 2021.
  4. 4

    Cascade learning from this and similar cases to professionals through Greater Manchester and borough governance and learning forums.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 23 November 2021.
  5. 5

    Communicate advice, guidance and available materials to all relevant providers to increase staff awareness.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 23 November 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

Present and share case learning with the Greater Manchester Quality Board and its participating commissioners, regulators, Healthwatch and NICE representatives.

Verbatim wording from the response

“1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.”

Source location

Response from NHS Greater Manchester
Page 2 · response
Published 23 November 2021

Open published response

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 pain-management and NICE guidance through quarterly Trafford local GP education sessions.

Verbatim wording from the response

“Pain management and NICE guidance have previously been discussed at Trafford local GP Education sessions, held quarterly. Please see documents attached below for further information on the Trafford CCG local guidance on Repeat Prescribing as well the National Institute for Clinical Excellence (NICE) guidance in relation to assessing and managing chronic pain in the over 16’s. The Repeat Prescribing guidance is currently under review and will be complete by 31st March 2022.”

Source location

Response from NHS Greater Manchester
Page 2 · response
Published 23 November 2021

Open published response

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

Monitor key learning points and recommendations to ensure they become embedded in practice.

Verbatim wording from the response

“In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. GMHSCP is committed to improving outcomes for the population of Greater Manchester.”

Source location

Response from NHS Greater Manchester
Page 3 · response
Published 23 November 2021

Open published response

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

Cascade learning from this and similar cases to professionals through Greater Manchester and borough governance and learning forums.

Verbatim wording from the response

“3. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through appropriate governance and learning forums.”

Source location

Response from NHS Greater Manchester
Page 3 · response
Published 23 November 2021

Open published response

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

Communicate advice, guidance and available materials to all relevant providers to increase staff awareness.

Verbatim wording from the response

“2. Communication to all ████████ providers to share appropriate advice and guidance and increase staff awareness regarding the range of materials that are already available.”

Source location

Response from NHS Greater Manchester
Page 3 · response
Published 23 November 2021

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