Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 27
Flixton Road Medical Centre Conduct follow-up audits of compliance with revised opioid prescribing protocols and safety measures, reviewing results and learning at practice meetings.
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Flixton Road Medical Centre Update electronic prescribing systems with enhanced safety alerts for high opioid use and point-of-care prescribing prompts.
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Flixton Road Medical Centre Disseminate case learning through TeamNet, clinical briefings and structured team-meeting reflection.
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Flixton Road Medical Centre Complete an audit of high-risk opioid prescribing to identify improvement needs and support appropriate monitoring.
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Flixton Road Medical Centre Revise opioid prescribing policy and introduce a prescribing protocol with escalation thresholds, rationale documentation and multidisciplinary oversight.
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Flixton Road Medical Centre Introduce mandatory staff training in opioid safety and polypharmacy.
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Flixton Road Medical Centre Develop a standardised communication protocol for documenting and coordinating care between clinical teams.
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Flixton Road Medical Centre Complete a comprehensive review of opioid prescribing practices.
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Flixton Road Medical Centre Require documented patient risk-benefit discussions and consideration of alternatives before new high-dose opioid initiation or dose escalation.
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Flixton Road Medical Centre Require regular structured medication reviews for high-dose opioid prescriptions, with defined intervals and GP and pharmacist oversight.
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Flixton Road Medical Centre Share key findings and learning points with Primary Care Network colleagues and Trafford practices.
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Flixton Road Medical Centre Develop an action plan addressing the concerns raised in the Prevention of Future Deaths report.
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NHS Greater Manchester Integrated Care Board Work with Manchester University colleagues to investigate and implement the SMASH dashboard opioid indicator for identifying and reviewing patients after hospital discharge.
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NHS Greater Manchester Integrated Care Board Collaborate with other localities and secondary-care pain clinics to explore multidisciplinary review of complex primary-care patients receiving high-dose opioids.
View source
NHS Greater Manchester Integrated Care Board Work with GP practices to increase use of the SMASH dashboard, including its opioid indicator.
View source
NHS Greater Manchester Integrated Care Board Attend trust-led case-based discussions to understand secondary-care opioid-prescribing challenges and their impact on primary care.
View source
NHS Greater Manchester Integrated Care Board Attend Regional Controlled Drugs Local Intelligence Network meetings to learn from incidents, maintain awareness and share good practice.
View source
NHS Greater Manchester Integrated Care Board Review patients flagged by the SMASH opioid indicator, identify primary-care review-process improvements and feed potential secondary-care improvements to the Opioid Safety Group.
View source
NHS Greater Manchester Integrated Care Board Use regular meetings with PCN clinical pharmacists to promote identification and prioritisation of opioid patients for structured medication review and signpost review resources.
View source
NHS Greater Manchester Integrated Care Board Work with other Greater Manchester localities to produce and implement standards for primary-care review of patients discharged on opioids.
View source
NHS Greater Manchester Integrated Care Board Produce and disseminate primary-care communications highlighting chronic-pain opioid risks, review expectations and available resources.
View source
NHS Greater Manchester Integrated Care Board Provide GP practices with opioid-prescribing data, including high-dose prescribing, and signpost resources supporting patient review.
View source
NHS Greater Manchester Integrated Care Board Attend the local hospital trust Opioid Safety Group to support primary-secondary care collaboration on reducing opioid harm.
View source
NHS Greater Manchester Integrated Care Board Increase awareness and accessibility of local services supporting opioid-patient review, including pain-clinic referral pathways and non-pharmacological pain-management support.
View source
NHS Greater Manchester Integrated Care Board Lead opioid risk reduction and pain-management work with colleagues to develop and implement harm-reduction strategies.
View source
NHS Greater Manchester Integrated Care Board Participate in the Medicines Safety Improvement Programme collaborative to implement a whole-system approach to high-risk opioid prescribing and share good practice.
View source
NHS Greater Manchester Integrated Care Board Represent Trafford in the Greater Manchester Pain Collaborative to identify and develop solutions for prescribing pain medicines.
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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 Limited review of long-term opiate prescribing
Wider context from the report “THE INQUEST HEARD EVIDENCE THAT Louise Rosendale had been prescribed opiates for many years despite the risks associated with long term opiate prescribing. The evidence before the inquest was that there had been very limited attempts to review the long term prescribing of opiates to her . The inquest was told that she had been identified as a patient on a long term opiate prescription in 2022. The next action had been a pharmacy review in July 2024.There was no evidence of long term detailed planning or oversight of these patients within the practice
” 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 Lack of long-term detailed planning and oversight of patients prescribed opiates
Wider context from the report “THE INQUEST HEARD EVIDENCE THAT Louise Rosendale had been prescribed opiates for many years despite the risks associated with long term opiate prescribing. The evidence before the inquest was that there had been very limited attempts to review the long term prescribing of opiates to her. The inquest was told that she had been identified as a patient on a long term opiate prescription in 2022. The next action had been a pharmacy review in July 2024.There was no evidence of long term detailed planning or oversight of these patients within the practice
” Open source report
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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 Conduct follow-up audits of compliance with revised opioid prescribing protocols and safety measures, reviewing results and learning at practice meetings.
Verbatim wording from the response “To ensure the effectiveness of the actions taken and to support continuous improvement, we will implement follow-up audits to monitor compliance with revised protocols and safety measures related to opiate prescribing. The audit results and learning will be reviewed at our practice meeting, where we will strive to ensure all new processes are acknowledged and embedded by all the clinical team.” Source location Response from Flixton Road Medical Centre
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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 Update electronic prescribing systems with enhanced safety alerts for high opioid use and point-of-care prescribing prompts.
Verbatim wording from the response “As part of the practice’s commitment to continuous learning and patient safety, a comprehensive review of opioid prescribing was undertaken. This included a revision of the opioid prescribing policy in line with current clinical guidelines, alongside the introduction of mandatory training for all prescribers to support safer opioid use. An audit of high-risk prescribing was completed to identify areas for improvement and ensure appropriate monitoring. Electronic safety alerts within the prescribing system were optimised to support clinical decision-making at the point of care. Structured medication reviews were reinforced as a routine part of ongoing care, particularly for patients on long-term high-dose opioids.” Source location Response from Flixton Road Medical Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate case learning through TeamNet, clinical briefings and structured team-meeting reflection.
Verbatim wording from the response “To ensure that the learning from this case is fully embedded across our practice, we have developed an action plan to address the concerns raised, which is enclosed with this response. Key elements of our learning dissemination include publication on our internal learning platform (TeamNet), briefing sessions with the clinical team, and structured reflection during team meetings.” Source location Response from Flixton Road Medical Centre
Open published response
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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 Complete an audit of high-risk opioid prescribing to identify improvement needs and support appropriate monitoring.
Verbatim wording from the response “As part of the practice’s commitment to continuous learning and patient safety, a comprehensive review of opioid prescribing was undertaken. This included a revision of the opioid prescribing policy in line with current clinical guidelines, alongside the introduction of mandatory training for all prescribers to support safer opioid use. An audit of high-risk prescribing was completed to identify areas for improvement and ensure appropriate monitoring. Electronic safety alerts within the prescribing system were optimised to support clinical decision-making at the point of care. Structured medication reviews were reinforced as a routine part of ongoing care, particularly for patients on long-term high-dose opioids.” Source location Response from Flixton Road Medical Centre
Open published response
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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 Revise opioid prescribing policy and introduce a prescribing protocol with escalation thresholds, rationale documentation and multidisciplinary oversight.
Verbatim wording from the response “As part of the practice’s commitment to continuous learning and patient safety, a comprehensive review of opioid prescribing was undertaken. This included a revision of the opioid prescribing policy in line with current clinical guidelines, alongside the introduction of mandatory training for all prescribers to support safer opioid use. An audit of high-risk prescribing was completed to identify areas for improvement and ensure appropriate monitoring. Electronic safety alerts within the prescribing system were optimised to support clinical decision-making at the point of care. Structured medication reviews were reinforced as a routine part of ongoing care, particularly for patients on long-term high-dose opioids.” Source location Response from Flixton Road Medical Centre
Open published response
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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 Introduce mandatory staff training in opioid safety and polypharmacy.
Verbatim wording from the response “As part of the practice’s commitment to continuous learning and patient safety, a comprehensive review of opioid prescribing was undertaken. This included a revision of the opioid prescribing policy in line with current clinical guidelines, alongside the introduction of mandatory training for all prescribers to support safer opioid use. An audit of high-risk prescribing was completed to identify areas for improvement and ensure appropriate monitoring. Electronic safety alerts within the prescribing system were optimised to support clinical decision-making at the point of care. Structured medication reviews were reinforced as a routine part of ongoing care, particularly for patients on long-term high-dose opioids.” Source location Response from Flixton Road Medical Centre
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 Develop a standardised communication protocol for documenting and coordinating care between clinical teams.
Verbatim wording from the response “In addition, a standardised communication protocol was developed to ensure consistent, clear, and timely documentation and coordination between clinical teams involved in patient care. These actions aim to strengthen prescribing safety, enhance patient outcomes, and support a culture of continuous quality improvement.” Source location Response from Flixton Road Medical Centre
Open published response
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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 Complete a comprehensive review of opioid prescribing practices.
Verbatim wording from the response “As part of the practice’s commitment to continuous learning and patient safety, a comprehensive review of opioid prescribing was undertaken. This included a revision of the opioid prescribing policy in line with current clinical guidelines, alongside the introduction of mandatory training for all prescribers to support safer opioid use. An audit of high-risk prescribing was completed to identify areas for improvement and ensure appropriate monitoring. Electronic safety alerts within the prescribing system were optimised to support clinical decision-making at the point of care. Structured medication reviews were reinforced as a routine part of ongoing care, particularly for patients on long-term high-dose opioids.” Source location Response from Flixton Road Medical Centre
Open published response
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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 Require documented patient risk-benefit discussions and consideration of alternatives before new high-dose opioid initiation or dose escalation.
Verbatim wording from the response “Additionally, any new initiation or dose escalation of high-level opioids requires a documented risk-benefit discussion with the patient, including exploration of alternative pain management strategies. This process is supported by ongoing staff training in opioid safety and polypharmacy and monitored through regular audits to ensure compliance and continuous improvement.” Source location Response from Flixton Road Medical Centre
Open published response
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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 Require regular structured medication reviews for high-dose opioid prescriptions, with defined intervals and GP and pharmacist oversight.
Verbatim wording from the response “As part of the practice’s commitment to continuous learning and patient safety, a comprehensive review of opioid prescribing was undertaken. This included a revision of the opioid prescribing policy in line with current clinical guidelines, alongside the introduction of mandatory training for all prescribers to support safer opioid use. An audit of high-risk prescribing was completed to identify areas for improvement and ensure appropriate monitoring. Electronic safety alerts within the prescribing system were optimised to support clinical decision-making at the point of care. Structured medication reviews were reinforced as a routine part of ongoing care, particularly for patients on long-term high-dose opioids.” Source location Response from Flixton Road Medical Centre
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 Share key findings and learning points with Primary Care Network colleagues and Trafford practices.
Verbatim wording from the response “In addition, we will share the key findings and learning points with our Primary Care Network (PCN) colleagues and across other practices within the Trafford area to support wider system learning and reinforce safe practice in the prescribing and management of opiates.” Source location Response from Flixton Road Medical Centre
Open published response
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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 an action plan addressing the concerns raised in the Prevention of Future Deaths report.
Verbatim wording from the response “To ensure that the learning from this case is fully embedded across our practice, we have developed an action plan to address the concerns raised, which is enclosed with this response. Key elements of our learning dissemination include publication on our internal learning platform (TeamNet), briefing sessions with the clinical team, and structured reflection during team meetings.” Source location Response from Flixton Road Medical Centre
Open published response
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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 Work with Manchester University colleagues to investigate and implement the SMASH dashboard opioid indicator for identifying and reviewing patients after hospital discharge.
Verbatim wording from the response “• Working with colleagues from Manchester University to investigate and implement use of the new Safety Medication (SMASH) dashboard indicator which identifies patients prescribed opioids within 30 days of discharge from hospital. The aim of the indicator is to facilitate identification and review of patients to prevent harm from long term opioid use.” Source location Response from Greater Manchester Integrated 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 Collaborate with other localities and secondary-care pain clinics to explore multidisciplinary review of complex primary-care patients receiving high-dose opioids.
Verbatim wording from the response “• Collaborate with colleagues from other GM localities and secondary care pain clinics to explore the potential for multidisciplinary team review of complex patients on high dose opioids in primary care.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Work with GP practices to increase use of the SMASH dashboard, including its opioid indicator.
Verbatim wording from the response “• Work with GP practices to increase use of the safety medication (SMASH) dashboard, including the new opioid indicator.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Attend trust-led case-based discussions to understand secondary-care opioid-prescribing challenges and their impact on primary care.
Verbatim wording from the response “• Attendance at trust-led case-based discussions regarding opioid prescribing to gain a better understanding of the challenges faced in secondary care and how these impact on primary care.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Attend Regional Controlled Drugs Local Intelligence Network meetings to learn from incidents, maintain awareness and share good practice.
Verbatim wording from the response “• Attendance at the Regional CD Local Intelligence Network meetings to ensure awareness of and learning from issues/incidents in other areas and share good practice.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 patients flagged by the SMASH opioid indicator, identify primary-care review-process improvements and feed potential secondary-care improvements to the Opioid Safety Group.
Verbatim wording from the response “• Review by a pharmacy technician and pharmacist from the team of patients flagged by the SMASH opioid indicator and identify improvements that can be made to primary care review processes as well as feeding back, via the trust Opioid Safety Group, potential improvements to secondary care processes.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Use regular meetings with PCN clinical pharmacists to promote identification and prioritisation of opioid patients for structured medication review and signpost review resources.
Verbatim wording from the response “• Discussion at regular meetings held with PCN clinical pharmacists to highlight the need to identify and prioritise patients prescribed opioids for structured medication reviews and ensuring they are aware of resources available to facilitate review, including the Greater Manchester Pain Management Resources Hub.” Source location Response from Greater Manchester Integrated 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 Work with other Greater Manchester localities to produce and implement standards for primary-care review of patients discharged on opioids.
Verbatim wording from the response “• Work with colleagues in other GM localities to produce and implement standards for primary care review of patients discharged on opioids.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Produce and disseminate primary-care communications highlighting chronic-pain opioid risks, review expectations and available resources.
Verbatim wording from the response “• Collaboration with a colleague from another locality to produce a communication for primary care to highlight the risks of opioids used in chronic pain, encourage review of these patients and signpost to resources available on the Greater Manchester Pain Management Resources Hub.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Provide GP practices with opioid-prescribing data, including high-dose prescribing, and signpost resources supporting patient review.
Verbatim wording from the response “• Provide data to GP Practices regarding their opioid prescribing, including high dose opioids, and ensure they are aware of resources available to facilitate review of patients.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Attend the local hospital trust Opioid Safety Group to support primary-secondary care collaboration on reducing opioid harm.
Verbatim wording from the response “• Attending the local hospital trust’s Opioid Safety Group to facilitate primary and secondary care colleagues working together to reduce the harm from opioids. One of the current areas of work for this group is the implementation of the GM Communication Standards for Opioids at Discharge.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Increase awareness and accessibility of local services supporting opioid-patient review, including pain-clinic referral pathways and non-pharmacological pain-management support.
Verbatim wording from the response “• Increase awareness, and ensure information is readily accessible to GP practice clinicians, regarding local services available to support the review of patients on opioids, including pain clinic referral pathways and non-pharmacological support for pain management.” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Lead opioid risk reduction and pain-management work with colleagues to develop and implement harm-reduction strategies.
Verbatim wording from the response “One of the pharmacists in the team leads on opioid risk reduction and pain management, collaborating with colleagues to share good practice and implement strategies for opioid risk reduction. This includes:” Source location Response from Greater Manchester Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in the Medicines Safety Improvement Programme collaborative to implement a whole-system approach to high-risk opioid prescribing and share good practice.
Verbatim wording from the response “• Taking part, along with a pharmacy technician from the Trafford team, in the Medicines Safety Improvement Programme (MedSIP) breakthrough series collaborative which aims to implement a whole system approach to high-risk opioid prescribing. This has resulted in sharing of good practice and closer working with other secondary and primary care colleagues across Greater Manchester.” Source location Response from Greater Manchester Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Represent Trafford in the Greater Manchester Pain Collaborative to identify and develop solutions for prescribing pain medicines.
Verbatim wording from the response “• Representing the Trafford Locality at the Greater Manchester Pain Collaborative which brings together stakeholders to identify and develop solutions to the challenges of prescribing pain medicines across Greater Manchester.” Source location Response from Greater Manchester Integrated Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Resource constraints limited the practice’s ability to undertake more proactive, structured opioid reviews.
Verbatim wording from the response “On reflection, several areas have been identified where care could have been improved. Earlier identification of risks associated with long-term high-dose opioid use may have prompted more timely interventions. Greater patient involvement in decision-making could have supported shared understanding and safer management plans. There was limited external input from specialist services in reviewing ongoing opioid prescribing, and an absence of a formal monitoring framework meant that risk mitigation strategies were not consistently applied. Resource constraints also impacted the ability to implement more proactive, structured reviews. Opportunities were missed for more proactive monitoring of opioid use, supported by a clear and structured communication protocol across the clinical team.” Source location Response from Flixton Road Medical Centre
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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 Structured medication reviews for opioid patients are limited by PCN clinical pharmacist capacity under the DES contract.
Verbatim wording from the response “Since October 2020, there has been a requirement, as part of the PCN Direct Enhanced Service (DES) contract, for GP practices to proactively identify and prioritise for structured medication review (SMR) patients using one or more potentially addictive medications from the following groups: opioids; gabapentinoids; benzodiazepines; and Z-drugs. However, the PCN DES also states that the number of SMRs that a PCN is required to offer will be determined and limited by their clinical pharmacist capacity.” Source location Response from Greater Manchester Integrated Care
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