PFD report

Edna May CLEATON · Prevention of Future Deaths report

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Issued 17 Dec 2015•Birmingham and Solihull

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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

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Concerns raised1

  1. Failure to ensure appropriate medical reviews of patients on citalopram before repeat prescriptions are issued
    Part of recurring concern: Failure to reliably conduct clinically required medication reviewsPart of recurring concern: Unreliable review and monitoring of repeat prescriptions
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.2

  1. Action

    Configure an electronic clinical-system prompt that prevents depression-coded repeat prescriptions without a documented review in the preceding six months.

    Stated by Midlands Medical PartnershipStated completedThe respondent said that this action was complete when they made their response on 17 December 2015.
  2. Action

    Implement a repeat-prescribing protocol requiring antidepressant reviews at least every six months before further prescriptions are issued.

    Stated by Midlands Medical PartnershipStated completedThe respondent said that this action was complete when they made their response on 17 December 2015.

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

  1. Position

    Existing repeat-prescribing protocols and electronic prompts are considered sufficient to ensure timely antidepressant reviews.

    Stated by Midlands Medical PartnershipExisting 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

Failure to ensure appropriate medical reviews of patients on citalopram before repeat prescriptions are issued

Wider context from the report

“(1) The evidence heard at the inquest was that patients on citalopram should be reviewed by a doctor every 3 – 6 months. This lady had not been reviewed for over 3 years. The practice need systems in place to ensure patients received appropriate medical reviews before repeat prescriptions are issued. Had regular reviews been undertaken it is possible that medical staff would have identified deterioration in the deceased and a care plan could have been instigated which may have avoided the pressure sores that developed. ”

Is this part of a recurring concern?

Yes — Failure to reliably conduct clinically required medication reviews; Unreliable review and monitoring of repeat prescriptions.

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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

Configure an electronic clinical-system prompt that prevents depression-coded repeat prescriptions without a documented review in the preceding six months.

Verbatim wording from the response

“We also have an automatic electronic protocol that has been built into the clinical system that is activated if repeat prescription is generated with a read code of depression. If a review has not taken place, then an automatic prompt will appear, reminding the prescriber of the need for a review before the prescription can be issued.”

Source location

Edna-Cleaton-Response
Page 2 · response
Published 17 December 2015

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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

Implement a repeat-prescribing protocol requiring antidepressant reviews at least every six months before further prescriptions are issued.

Verbatim wording from the response

“When a repeat prescription for antidepressants is set up it is usually only for a maximum of six months. After this period a review must take place.”

Source location

Edna-Cleaton-Response
Page 1 · response
Published 17 December 2015

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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

Existing repeat-prescribing protocols and electronic prompts are considered sufficient to ensure timely antidepressant reviews.

Verbatim wording from the response

“This has been agreed by all the doctors at Jockey Road Medical Centre. When a repeat prescription is generated, that person must ensure that an appropriate review has happened in the previous six months.”

Source location

Edna-Cleaton-Response
Page 2 · response
Published 17 December 2015

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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