PFD report

Amanda Jane Kramer · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 11 Sep 2023•East 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.

View original report
Concerns
3

Raised in this report

Recipients
4

Named on the report

Responses found
3

Of 4 recipients

Stated actions
17

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to review Zopiclone use despite high-risk medication-taking behaviour
    Part of recurring concern: Failure to identify clinically significant medication risksPart of recurring concern: Failure to reliably conduct clinically required medication reviewsPart of recurring concern: Inadequate review of long-term medication use
  2. Central nervous system depression risk from Zopiclone
  3. Dependency risk from Zopiclone
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.13

  1. Action

    Improve team handovers by documenting patient information, care plans and professional responsibilities, including primary-care prescribing arrangements, and audit effectiveness.

    Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
  2. Action

    Coordinate primary and secondary care medication monitoring through an established integrated-care-system workstream and improve information sharing.

    Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2023.
  3. Action

    Increase Crisis and Home Treatment team staffing through additional pharmacist posts.

    Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.

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

  1. Position

    Prescribing and medication review decisions rest with the GP or responsible clinician, who must determine treatment with the patient.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 review Zopiclone use despite high-risk medication-taking behaviour

Wider context from the report

“1. Zopiclone is a drug licenced for the treatment of short-term insomnia. The risks associated with the drug are first, that it is a central nervous system depressant and second, that patients prescribed the drug can form a dependency upon it. 2. Mrs Kramer was prescribed Zopiclone for 18 years. 3. Despite the deceased being under the care of both a GP and a secondary mental health trust prior to her death. No clear evidence emerged in this inquest that anyone had reviewed Mrs Kramer's use of this drug even when Mrs Kramer had demonstrated a pattern of high-risk behaviour by deliberately overdosing on prescribed medication. ”

Is this part of a recurring concern?

Yes — Failure to identify clinically significant medication risks; Failure to reliably conduct clinically required medication reviews; Inadequate review of long-term medication use.

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

Central nervous system depression risk from Zopiclone

Wider context from the report

“1. Zopiclone is a drug licenced for the treatment of short-term insomnia. The risks associated with the drug are first, that it is a central nervous system depressant and second, that patients prescribed the drug can form a dependency upon it. 2. Mrs Kramer was prescribed Zopiclone for 18 years. 3. Despite the deceased being under the care of both a GP and a secondary mental health trust prior to her death. No clear evidence emerged in this inquest that anyone had reviewed Mrs Kramer's use of this drug even when Mrs Kramer had demonstrated a pattern of high-risk behaviour by deliberately overdosing on prescribed medication. ”

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

Dependency risk from Zopiclone

Wider context from the report

“1. Zopiclone is a drug licenced for the treatment of short-term insomnia. The risks associated with the drug are first, that it is a central nervous system depressant and second, that patients prescribed the drug can form a dependency upon it. 2. Mrs Kramer was prescribed Zopiclone for 18 years. 3. Despite the deceased being under the care of both a GP and a secondary mental health trust prior to her death. No clear evidence emerged in this inquest that anyone had reviewed Mrs Kramer's use of this drug even when Mrs Kramer had demonstrated a pattern of high-risk behaviour by deliberately overdosing on prescribed medication. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Improve team handovers by documenting patient information, care plans and professional responsibilities, including primary-care prescribing arrangements, and audit effectiveness.

Verbatim wording from the response

“3. The Trust has also worked with staff to ensure that there is effective handover of information between teams so that responsibilities are clear. In particular, there has been a focus on ensuring comprehensive documentation of patient information at the point of handover from one team to another. The effectiveness of this is being audited, and in the most recent audit undertaken (a random sample of 20 patients), all records were clear and reflected a comprehensive handover of the care plan and responsibilities for different professionals involved. This includes situations in which prescribing is taking place within primary care.”

Source location

Response from North East London Foundation Trust
Page 2 · response
Published 15 September 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

Coordinate primary and secondary care medication monitoring through an established integrated-care-system workstream and improve information sharing.

Verbatim wording from the response

“2. A workstream has been established across the primary and secondary care partners in the North East London Integrated Care System. This is overseeing improvements to the co-ordination of medication monitoring for patients receiving Benzodiazepines and Z-Drugs, including significant work on the co-ordination of information between primary and secondary care to ensure that accurate information is in place to enable the effective review and monitoring of patients who have been prescribed such medication.”

Source location

Response from North East London Foundation Trust
Page 2 · response
Published 15 September 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

Increase Crisis and Home Treatment team staffing through additional pharmacist posts.

Verbatim wording from the response

“4. Staffing in Crisis and Home Treatment teams has been increased, with the addition of extra pharmacist posts. This will enable improved medicine reconciliation at the point of discharge from hospital, and ensure that prescriptions for Zopiclone amongst other medication are effectively monitored and reconciled throughout the patient’s journey. This increased capacity will also give more pharmacy support to work with individual patients at this point of transfer and transition, including work on medication education for both patients and prescribers that will help to address risks associated with these medications.”

Source location

Response from North East London Foundation Trust
Page 2 · response
Published 15 September 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

Train staff in the safe prescribing and management of Z-drugs and benzodiazepines through repeat sessions.

Verbatim wording from the response

“In support of this work, staff have received training on the safe prescribing and management of Z-drugs and Benzodiazepines and this is being arranged on a repeat basis, with the next session taking place on 29 November 2023.”

Source location

Response from North East London Foundation Trust
Page 2 · response
Published 15 September 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

Use additional pharmacy capacity to improve discharge medication reconciliation, monitor and reconcile Zopiclone prescriptions, and provide medication education during transfers.

Verbatim wording from the response

“4. Staffing in Crisis and Home Treatment teams has been increased, with the addition of extra pharmacist posts. This will enable improved medicine reconciliation at the point of discharge from hospital, and ensure that prescriptions for Zopiclone amongst other medication are effectively monitored and reconciled throughout the patient’s journey. This increased capacity will also give more pharmacy support to work with individual patients at this point of transfer and transition, including work on medication education for both patients and prescribers that will help to address risks associated with these medications.”

Source location

Response from North East London Foundation Trust
Page 2 · response
Published 15 September 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 Zopiclone prescriptions within two weeks, identify existing patients for review, provide senior clinical oversight, and audit compliance six-monthly.

Verbatim wording from the response

“1. Patients who are initiated on Zopiclone now have a medical review of this medication within at least 2 weeks of the initial prescription date recorded in their care plan, whilst existing patients are being identified and reviewed. Senior clinical oversight has also been put in place to support this review for all patients prescribed this medication. The Trust has also put in place a 6 monthly audit process of this to help support this improvement in practice. The last of these audits was undertaken in October 2023, identifying one patient where a review was required, but that all other reviews had taken place. In circumstances where prescriptions remain in place for longer periods of time, the risks and rationale for this are discussed with patients and medical and care co-ordinator staff are keeping this under careful review.”

Source location

Response from North East London Foundation Trust
Page 2 · response
Published 15 September 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

Apply the acute-prescription policy to new Zopiclone and Zolpidem requests.

Verbatim wording from the response

“3. All prescriptions of Zopiclone and Zolpidem have been reviewed to ensure they are acute, rather than repeat prescriptions; this will be a policy for new requests as well. This will also provide opportunities for more frequent reviews and discussion on how the withdrawal plan is being achieved with the patient. All quantities on prescription are reduced to a maximum 2-week supply.”

Source location

Response from Wood Street Health Centre
Page 2 · response
Published 15 September 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

Add as-required, dose-reduction and cessation instructions to Zopiclone and Zolpidem prescriptions and inform local community pharmacists of the reduction plan.

Verbatim wording from the response

“4. The dosage instructions now state on the prescription that the medication is to be used on a ‘as required’ basis, not regularly; and to reduce the dosage down and stop when appropriate, so to remind the patient and the community pharmacist of the withdrawal plan. All local community pharmacists have been informed of the Practice’s plan and the shared goal of reducing these prescriptions and to work with the Practice to achieve it.”

Source location

Response from Wood Street Health Centre
Page 2 · response
Published 15 September 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

Conduct medication reviews every four weeks where possible, focusing on reduction according to withdrawal symptoms, risk and support.

Verbatim wording from the response

“2. Where possible, all patients on Zopiclone or Zolpidem will have a medication review every 4 weeks; such review will focus on reducing the regimen of their medication, depending on withdrawal symptoms, level of risk and support structure.”

Source location

Response from Wood Street Health Centre
Page 2 · response
Published 15 September 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 Zopiclone and Zolpidem prescriptions as acute rather than repeat prescriptions and limit quantities to a maximum two-week supply.

Verbatim wording from the response

“3. All prescriptions of Zopiclone and Zolpidem have been reviewed to ensure they are acute, rather than repeat prescriptions; this will be a policy for new requests as well. This will also provide opportunities for more frequent reviews and discussion on how the withdrawal plan is being achieved with the patient. All quantities on prescription are reduced to a maximum 2-week supply.”

Source location

Response from Wood Street Health Centre
Page 2 · response
Published 15 September 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’ Zopiclone or Zolpidem medication and develop reduction, cessation or safer-alternative plans.

Verbatim wording from the response

“1. All patients being prescribed with Zopiclone or Zolpidem have been identified via an audit, enclosed with this response as Exhibit 1; the Practice is in the process of reviewing their medication – the progress of this can be demonstrated in the re-audit, undertaken in October 2023 (Exhibit 2). The goal is for each patient to have a plan in place to reduce and eventually stop the medication or change it to a safer alternative. Notification letters of these actions and patient leaflets will be sent to all patients on Zopiclone and Zolpidem. The completed plans have been coded onto the patients’ notes on the EMIS computer system for both healthcare professionals and administrators to be aware of the care plan and not deviate from it.”

Source location

Response from Wood Street Health Centre
Page 2 · response
Published 15 September 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

Code completed medication plans in EMIS so healthcare professionals and administrators can follow them.

Verbatim wording from the response

“1. All patients being prescribed with Zopiclone or Zolpidem have been identified via an audit, enclosed with this response as Exhibit 1; the Practice is in the process of reviewing their medication – the progress of this can be demonstrated in the re-audit, undertaken in October 2023 (Exhibit 2). The goal is for each patient to have a plan in place to reduce and eventually stop the medication or change it to a safer alternative. Notification letters of these actions and patient leaflets will be sent to all patients on Zopiclone and Zolpidem. The completed plans have been coded onto the patients’ notes on the EMIS computer system for both healthcare professionals and administrators to be aware of the care plan and not deviate from it.”

Source location

Response from Wood Street Health Centre
Page 2 · response
Published 15 September 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

Audit patients prescribed Zopiclone or Zolpidem to identify those requiring medication review.

Verbatim wording from the response

“1. All patients being prescribed with Zopiclone or Zolpidem have been identified via an audit, enclosed with this response as Exhibit 1; the Practice is in the process of reviewing their medication – the progress of this can be demonstrated in the re-audit, undertaken in October 2023 (Exhibit 2). The goal is for each patient to have a plan in place to reduce and eventually stop the medication or change it to a safer alternative. Notification letters of these actions and patient leaflets will be sent to all patients on Zopiclone and Zolpidem. The completed plans have been coded onto the patients’ notes on the EMIS computer system for both healthcare professionals and administrators to be aware of the care plan and not deviate from it.”

Source location

Response from Wood Street Health Centre
Page 2 · response
Published 15 September 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

Prescribing and medication review decisions rest with the GP or responsible clinician, who must determine treatment with the patient.

Verbatim wording from the response

“As I am sure you will be aware, GPs and other prescribers are ultimately responsible for their own prescribing decisions. The decision to prescribe a particular product is a clinical one and should be based on the patient’s medical needs. The process of reviewing medication is one in which the GP or responsible clinician work together”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 15 September 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.4

  1. 1

    Send notification letters and patient leaflets to patients prescribed Zopiclone or Zolpidem.

    Stated by PracticeStated plannedThe respondent said that this action was planned when they made their response on 15 September 2023.
  2. 2

    Implement a joint care policy with secondary care providers for patients receiving Zopiclone or Zolpidem under shared care.

    Stated by PracticeStated plannedThe respondent said that this action was planned when they made their response on 15 September 2023.
  3. 3

    Implement patient alerts identifying Zopiclone or Zolpidem patients to out-of-hours and hospital healthcare providers.

    Stated by PracticeStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
  4. 4

    Prepare a policy for prescribing Zopiclone and Zolpidem under shared care arrangements.

    Stated by PracticeStated completedThe respondent said that this action was complete when they made their response on 15 September 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

Send notification letters and patient leaflets to patients prescribed Zopiclone or Zolpidem.

Verbatim wording from the response

“1. All patients being prescribed with Zopiclone or Zolpidem have been identified via an audit, enclosed with this response as Exhibit 1; the Practice is in the process of reviewing their medication – the progress of this can be demonstrated in the re-audit, undertaken in October 2023 (Exhibit 2). The goal is for each patient to have a plan in place to reduce and eventually stop the medication or change it to a safer alternative. Notification letters of these actions and patient leaflets will be sent to all patients on Zopiclone and Zolpidem. The completed plans have been coded onto the patients’ notes on the EMIS computer system for both healthcare professionals and administrators to be aware of the care plan and not deviate from it.”

Source location

Response from Wood Street Health Centre
Page 2 · response
Published 15 September 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

Implement a joint care policy with secondary care providers for patients receiving Zopiclone or Zolpidem under shared care.

Verbatim wording from the response

“5. For the patients who are under a shared care arrangement, the Practice will implement a joint care policy with their secondary care provider.”

Source location

Response from Wood Street Health Centre
Page 2 · response
Published 15 September 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

Implement patient alerts identifying Zopiclone or Zolpidem patients to out-of-hours and hospital healthcare providers.

Verbatim wording from the response

“Patient alert system notification has also been put in place for all these patients as an identification of other healthcare providers both in the out of hours service and hospital trusts.”

Source location

Response from Wood Street Health Centre
Page 2 · response
Published 15 September 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

Prepare a policy for prescribing Zopiclone and Zolpidem under shared care arrangements.

Verbatim wording from the response

“6. The Practice has prepared a new policy for prescribing Zopiclone and Zolpidem under shared care arrangements – this is enclosed with this response as Exhibit 3.”

Source location

Response from Wood Street Health Centre
Page 3 · response
Published 15 September 2023

Open published response
Back to top

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