PFD report

SAM ROBSON PRINGLE · Prevention of Future Deaths report

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Issued 22 Apr 2020•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.

View original report
Concerns
1

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
7

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 psychiatrists to comply with the shared care protocol when requesting GP initiation of Lithium prescriptions
    Part of recurring concern: Unreliable doctor-to-doctor coordination of prescribing
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.4

  1. Action

    Review all Greater Manchester Shared Care Protocols using risk-based prioritisation, agreed review timescales, COVID-related practice changes and relevant stakeholder learning.

    Stated by Greater Manchester Medicines Management Group and NHS Greater Manchester Integrated Care Board and Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2020.
  2. Action

    Communicate the shared-care communication failure to general-practice colleagues and require similar problems to be escalated to the CCG.

    Stated by Greater Manchester Medicines Management Group and NHS Greater Manchester Integrated Care Board and Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.
  3. Action

    Provide assurance that Greater Manchester Shared Care Protocol implementation standards are followed, including assurance where local processes deviate.

    Stated by Greater Manchester Medicines Management Group and NHS Greater Manchester Integrated Care Board and Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2020.

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 psychiatrists to comply with the shared care protocol when requesting GP initiation of Lithium prescriptions

Wider context from the report

“(1) The inquest heard evidence that some psychiatrists are asking GPs to instigate prescriptions of Lithium, knowing that the shared care protocol (should) prevent GPs from doing so; as a result the provision of Lithium to mentally ill patients is either not happening or is being delayed, with potentially fatal results. ”

Is this part of a recurring concern?

Yes — Unreliable doctor-to-doctor coordination of prescribing.

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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

Review all Greater Manchester Shared Care Protocols using risk-based prioritisation, agreed review timescales, COVID-related practice changes and relevant stakeholder learning.

Verbatim wording from the response

“• A full review of the content of all Shared Care Protocols is required so as to ensure consistency, improve safety and prevent any delay for patients accessing their medications as occurred in Mr Pringle’s case. o Agree a risk based prioritisation of SCP review o Agree timescale for review with GMMMG and GM Directors of Commissioning”

Source location

2020-0101-Response-from-Greater-Manchester-Medicines-Management-Group-NHS-Stockport-Clinical-Commission-Groupw.pdf
Page 2 · response
Published 18 May 2020

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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

Communicate the shared-care communication failure to general-practice colleagues and require similar problems to be escalated to the CCG.

Verbatim wording from the response

“Stockport CCG have a quality scheme in place, which facilitates shared care and Dr Woodworth has communicated to colleagues in General Practice to highlight this issue and ensure that any similar problems with a shared care process are highlighted to the CCG, such that there is oversight and an opportunity to ensure patients get their treatment safely and in a timely manner.”

Source location

2020-0101-Response-from-Greater-Manchester-Medicines-Management-Group-NHS-Stockport-Clinical-Commission-Groupw.pdf
Page 2 · response
Published 18 May 2020

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 assurance that Greater Manchester Shared Care Protocol implementation standards are followed, including assurance where local processes deviate.

Verbatim wording from the response

“• Make recommendations for a unified GM position on implementation of SCPs. o This will ideally be a de minimus, standardised GM process. o Where a GM standard is not adopted due to local commissioning considerations, clinicians must have access to an agreed local process, which is clearly documented and communicated. o GMMMG to assure implementation of standards.”

Source location

2020-0101-Response-from-Greater-Manchester-Medicines-Management-Group-NHS-Stockport-Clinical-Commission-Groupw.pdf
Page 3 · response
Published 18 May 2020

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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

Develop recommendations for a unified Greater Manchester process for implementing Shared Care Protocols, including clearly documented local arrangements where the standard is not adopted.

Verbatim wording from the response

“• Make recommendations for a unified GM position on implementation of SCPs. o This will ideally be a de minimus, standardised GM process. o Where a GM standard is not adopted due to local commissioning considerations, clinicians must have access to an agreed local process, which is clearly documented and communicated. o GMMMG to assure implementation of standards.”

Source location

2020-0101-Response-from-Greater-Manchester-Medicines-Management-Group-NHS-Stockport-Clinical-Commission-Groupw.pdf
Page 3 · response
Published 18 May 2020

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.3

  1. 1

    Develop business cases for Greater Manchester approval where Shared Care Protocol pathways require additional funding or assurance.

    Stated by Greater Manchester Medicines Management Group and NHS Greater Manchester Integrated Care Board and Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2020.
  2. 2

    Discuss the case with the Drugs and Therapeutics Committee and reinforce communication requirements for safe transfers of care.

    Stated by Greater Manchester Medicines Management Group and NHS Greater Manchester Integrated Care Board and Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.
  3. 3

    Ensure independent-sector providers comply with the same Greater Manchester shared-care standards as NHS providers.

    Stated by Greater Manchester Medicines Management Group and NHS Greater Manchester Integrated Care Board and Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2020.

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 business cases for Greater Manchester approval where Shared Care Protocol pathways require additional funding or assurance.

Verbatim wording from the response

“• Develop business cases for GM approval where additional funding and assurance is required, o Consider approving of SCPs and related pathways as policy only when funding and assurance in place. o Consider reconciliation of local approval of GM standards to assure consistency for all GM residents. o Assurance required if local process deviates from the agreed position.”

Source location

2020-0101-Response-from-Greater-Manchester-Medicines-Management-Group-NHS-Stockport-Clinical-Commission-Groupw.pdf
Page 3 · response
Published 18 May 2020

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 the case with the Drugs and Therapeutics Committee and reinforce communication requirements for safe transfers of care.

Verbatim wording from the response

“Pennine Care senior managers and clinicians have discussed the case with colleagues at the Drugs and Therapeutic Committee and reassured the importance of communication for safe transfers of care.”

Source location

2020-0101-Response-from-Greater-Manchester-Medicines-Management-Group-NHS-Stockport-Clinical-Commission-Groupw.pdf
Page 2 · response
Published 18 May 2020

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

Ensure independent-sector providers comply with the same Greater Manchester shared-care standards as NHS providers.

Verbatim wording from the response

“• Ensure all independent sector providers comply with the same GM standards as NHS providers”

Source location

2020-0101-Response-from-Greater-Manchester-Medicines-Management-Group-NHS-Stockport-Clinical-Commission-Groupw.pdf
Page 3 · response
Published 18 May 2020

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