PFD report

Glenn Anthony LOCKWOOD · Prevention of Future Deaths report

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Issued 17 Nov 2023•Inner North London

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 raised5

  1. Possible deficiencies in record keeping for Pregabalin prescriptions
    Part of recurring concern: Inadequate recording of medication prescribing decisions
  2. Failure to monitor Pregabalin for signs of abuse
    Part of recurring concern: Inadequate safeguards against misuse of medicines with abuse potential
  3. Serious Event Analysis failing to fully explore relevant risks
    Part of recurring concern: Inadequate safety incident investigationsPart of recurring concern: Unreliable formal safety-incident management processes
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

    Document medication dose or tablet-strength changes and notify patients of those changes.

    Stated by Limehouse PracticeStated plannedThe respondent said that this action was planned when they made their response on 6 December 2023.
  2. Action

    Review identified patients’ medication and discuss with RESET whether it should prescribe their opiate substitute and other dependence-potential medicines.

    Stated by Limehouse PracticeStated plannedThe respondent said that this action was planned when they made their response on 6 December 2023.
  3. Action

    Provide all prescribers with refresher training on EMIS medication history and prescribing dependence-potential medicines.

    Stated by Limehouse PracticeStated in progressThe respondent said that this action was in progress when they made their response on 6 December 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The Pregabalin dose was within BNF ranges and prescribed for a licensed indication, making the increase a reasonable response to reported anxiety.

    Stated by Limehouse PracticeDisputes 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

Possible deficiencies in record keeping for Pregabalin prescriptions

Wider context from the report

“(1) Mr Lockwood’s drug treatment provider wrote to his GP in August 2021 to advise caution “with regard to other medicines with potential for abuse.” According to the British National Formulary, Pregabalin should be monitored for “signs of abuse”. The evidence I received did not reassure me that sufficient steps were taken to monitor for signs of Pregabalin abuse, particularly in a patient with known history of drug abuse. (2) The statement received from Mr Lockwood’s GP alluded to the fact that there were possible record keeping and prescribing issues surrounding Mr Lockwood’s prescriptions for Pregabalin. As a result, a Serious Event Analysis was conducted. In response to written queries from me, The Limehouse Practice responded by email on 14 November 2023. That email alluded to potential errors within the Serious Event Analysis and stated that the Serious Event Analysis would be re-opened and revisited. As such, I am not reassured that relevant risks have fully explored and/or any required action(s) taken. ”

Is this part of a recurring concern?

Yes — Inadequate recording of medication prescribing decisions.

Open source report

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 monitor Pregabalin for signs of abuse

Wider context from the report

“(1) Mr Lockwood’s drug treatment provider wrote to his GP in August 2021 to advise caution “with regard to other medicines with potential for abuse.” According to the British National Formulary, Pregabalin should be monitored for “signs of abuse”. The evidence I received did not reassure me that sufficient steps were taken to monitor for signs of Pregabalin abuse, particularly in a patient with known history of drug abuse. (2) The statement received from Mr Lockwood’s GP alluded to the fact that there were possible record keeping and prescribing issues surrounding Mr Lockwood’s prescriptions for Pregabalin. As a result, a Serious Event Analysis was conducted. In response to written queries from me, The Limehouse Practice responded by email on 14 November 2023. That email alluded to potential errors within the Serious Event Analysis and stated that the Serious Event Analysis would be re-opened and revisited. As such, I am not reassured that relevant risks have fully explored and/or any required action(s) taken. ”

Is this part of a recurring concern?

Yes — Inadequate safeguards against misuse of medicines with abuse potential.

Open source report

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

Serious Event Analysis failing to fully explore relevant risks

Wider context from the report

“(1) Mr Lockwood’s drug treatment provider wrote to his GP in August 2021 to advise caution “with regard to other medicines with potential for abuse.” According to the British National Formulary, Pregabalin should be monitored for “signs of abuse”. The evidence I received did not reassure me that sufficient steps were taken to monitor for signs of Pregabalin abuse, particularly in a patient with known history of drug abuse. (2) The statement received from Mr Lockwood’s GP alluded to the fact that there were possible record keeping and prescribing issues surrounding Mr Lockwood’s prescriptions for Pregabalin. As a result, a Serious Event Analysis was conducted. In response to written queries from me, The Limehouse Practice responded by email on 14 November 2023. That email alluded to potential errors within the Serious Event Analysis and stated that the Serious Event Analysis would be re-opened and revisited. As such, I am not reassured that relevant risks have fully explored and/or any required action(s) taken. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations; Unreliable formal safety-incident management processes.

Open source report

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

Possible deficiencies in prescribing Pregabalin

Wider context from the report

“(1) Mr Lockwood’s drug treatment provider wrote to his GP in August 2021 to advise caution “with regard to other medicines with potential for abuse.” According to the British National Formulary, Pregabalin should be monitored for “signs of abuse”. The evidence I received did not reassure me that sufficient steps were taken to monitor for signs of Pregabalin abuse, particularly in a patient with known history of drug abuse. (2) The statement received from Mr Lockwood’s GP alluded to the fact that there were possible record keeping and prescribing issues surrounding Mr Lockwood’s prescriptions for Pregabalin. As a result, a Serious Event Analysis was conducted. In response to written queries from me, The Limehouse Practice responded by email on 14 November 2023. That email alluded to potential errors within the Serious Event Analysis and stated that the Serious Event Analysis would be re-opened and revisited. As such, I am not reassured that relevant risks have fully explored and/or any required action(s) taken. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 take required actions following risk analysis

Wider context from the report

“(1) Mr Lockwood’s drug treatment provider wrote to his GP in August 2021 to advise caution “with regard to other medicines with potential for abuse.” According to the British National Formulary, Pregabalin should be monitored for “signs of abuse”. The evidence I received did not reassure me that sufficient steps were taken to monitor for signs of Pregabalin abuse, particularly in a patient with known history of drug abuse. (2) The statement received from Mr Lockwood’s GP alluded to the fact that there were possible record keeping and prescribing issues surrounding Mr Lockwood’s prescriptions for Pregabalin. As a result, a Serious Event Analysis was conducted. In response to written queries from me, The Limehouse Practice responded by email on 14 November 2023. That email alluded to potential errors within the Serious Event Analysis and stated that the Serious Event Analysis would be re-opened and revisited. As such, I am not reassured that relevant risks have fully explored and/or any required action(s) taken. ”

Is this part of a recurring concern?

Yes — Failure to implement identified safety actions.

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

Document medication dose or tablet-strength changes and notify patients of those changes.

Verbatim wording from the response

“3. If any changes are made in doses of medication or tablet strength, this must be documented in EMIS consultation notes so there is a clearly identifiable rationale for any change. Patients should also be notified of any change in drug dosage / tablet strength.”

Source location

Response from The Limehouse Practice
Page 4 · response
Published 6 December 2023

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

Review identified patients’ medication and discuss with RESET whether it should prescribe their opiate substitute and other dependence-potential medicines.

Verbatim wording from the response

“2. We are carrying out a search to identify all patients on Pregabalin/diazepam or similar medications who are also prescribed opiate substitute treatment, either at RESET or in shared care. We will carry out a medication review for those patients and discuss with RESET and”

Source location

Response from The Limehouse Practice
Page 3 · response
Published 6 December 2023

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 all prescribers with refresher training on EMIS medication history and prescribing dependence-potential medicines.

Verbatim wording from the response

“4. Protected Learning Time is to be used to provide refresher training to all prescribers about EMIS prescribing function and how to view previous medication issues / amendments, as well as further training on prescribing drugs with potential for dependence. I have contacted the CGL/RESET consultant and am awaiting a response from them about agreeing a date for training.”

Source location

Response from The Limehouse Practice
Page 4 · response
Published 6 December 2023

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

Introduce three-monthly face-to-face reviews for patients prescribed dependence-inducing medicines, including Pregabalin, gabapentin, benzodiazepines and oxycodone.

Verbatim wording from the response

“1. We will ensure 3 monthly face to face reviews for patients on Pregabalin, gabapentin, benzodiazepines, oxycodone and other dependence inducing medications.”

Source location

Response from The Limehouse Practice
Page 3 · response
Published 6 December 2023

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

The Pregabalin dose was within BNF ranges and prescribed for a licensed indication, making the increase a reasonable response to reported anxiety.

Verbatim wording from the response

“In December 2022 Mr Lockwood was reviewed and he reported increased anxiety symptoms. The GP suggested this dose increase as a response to Mr Lockwood’s reported increased anxiety. The dose is within the BNF recommended ranges, and this medication was prescribed for anxiety, one of the licenced indications for this drug. This does therefore seem a reasonable course of action. That doctor reduced the length of the prescription to two weeks instead of the usual four weeks.”

Source location

Response from The Limehouse Practice
Page 3 · response
Published 6 December 2023

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

The Practice could not arrange a timely SEA because it received no hospital notification or medical cause of death until after the inquest.

Verbatim wording from the response

“Unfortunately, we did not receive any further information from the hospital or notification of Mr Lockwood’s death until a letter dated 30 June 2023 was received from the Senior Coroner’s officer on 3 July 2023. At that stage we were unaware of the medical cause of death to allow us to consider arranging for an SEA to be carried out. We only received details of the medical cause of death following the conclusion of the inquest. We have taken steps to ensure that requests for reports and correspondence with the Coroner’s office are brought to the attention of the partners so that we can ensure that all matters relevant to the Coroner’s investigation and inquiry are dealt with and that, where appropriate, we can arrange for an SEA to be undertaken in a timely manner.”

Source location

Response from The Limehouse Practice
Page 4 · response
Published 6 December 2023

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

There had been no previous early requests or concerns about Pregabalin misuse before the mistaken early-request concern arose.

Verbatim wording from the response

“Until December 2022, Mr Lockwood continued to receive prescriptions for Pregabalin at four weekly intervals when the duration was changed to two weekly. There had been no previous incidences of early requesting of Pregabalin, or concerns that the patient was misusing or over-using this medication.”

Source location

Response from The Limehouse Practice
Page 2 · response
Published 6 December 2023

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.2

  1. 1

    Ensure requests for reports and correspondence from the Coroner’s office are brought to partners’ attention to support timely Serious Event Analyses where appropriate.

    Stated by Limehouse PracticeStated completedThe respondent said that this action was complete when they made their response on 6 December 2023.
  2. 2

    Search records to identify patients receiving Pregabalin, diazepam or similar medicines alongside opiate substitute treatment.

    Stated by Limehouse PracticeStated in progressThe respondent said that this action was in progress when they made their response on 6 December 2023.

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 requests for reports and correspondence from the Coroner’s office are brought to partners’ attention to support timely Serious Event Analyses where appropriate.

Verbatim wording from the response

“Unfortunately, we did not receive any further information from the hospital or notification of Mr Lockwood’s death until a letter dated 30 June 2023 was received from the Senior Coroner’s officer on 3 July 2023. At that stage we were unaware of the medical cause of death to allow us to consider arranging for an SEA to be carried out. We only received details of the medical cause of death following the conclusion of the inquest. We have taken steps to ensure that requests for reports and correspondence with the Coroner’s office are brought to the attention of the partners so that we can ensure that all matters relevant to the Coroner’s investigation and inquiry are dealt with and that, where appropriate, we can arrange for an SEA to be undertaken in a timely manner.”

Source location

Response from The Limehouse Practice
Page 4 · response
Published 6 December 2023

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

Search records to identify patients receiving Pregabalin, diazepam or similar medicines alongside opiate substitute treatment.

Verbatim wording from the response

“2. We are carrying out a search to identify all patients on Pregabalin/diazepam or similar medications who are also prescribed opiate substitute treatment, either at RESET or in shared care. We will carry out a medication review for those patients and discuss with RESET and”

Source location

Response from The Limehouse Practice
Page 3 · response
Published 6 December 2023

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