PFD report

Samuel Martin BROWN · Prevention of Future Deaths report

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Issued 4 Dec 2025•South Yorkshire (Eastern)

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

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 raised2

  1. Failure to review medications to check that they are required
  2. Failure of the primary care prescribing regime to identify potential addiction and drug-seeking behaviour
    Part of recurring concern: Inadequate safeguards against misuse of medicines with abuse potential
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 existing guidance on recording drug-seeking behaviour in clinical records and sharing flags through the Summary Care Record.

    Stated by NHS South Yorkshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2025.
  2. Action

    Commission primary-care prescribing incentive schemes requiring opioid patient reviews to prevent avoidable harm.

    Stated by NHS South Yorkshire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 December 2025.
  3. Action

    Develop prescribing resources supporting practices to review patients and reduce opioid and co-prescribed opioid-gabapentinoid prescribing where appropriate.

    Stated by NHS South Yorkshire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 December 2025.

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

  1. Position

    Review of 2022–2025 prescribing data found no outlying opioid-prescribing concerns at the relevant practices.

    Stated by NHS South Yorkshire Integrated Care BoardDisputes 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

Failure to review medications to check that they are required

Wider context from the report

“As the commissioners for primary care services I am concerned that the prescribing regime in primary care did not identify potential addiction and drug seeking behaviour or review medications with a view to checking they are actually required. ”

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 of the primary care prescribing regime to identify potential addiction and drug-seeking behaviour

Wider context from the report

“As the commissioners for primary care services I am concerned that the prescribing regime in primary care did not identify potential addiction and drug seeking behaviour or review medications with a view to checking they are actually required. ”

Is this part of a recurring concern?

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

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

Review existing guidance on recording drug-seeking behaviour in clinical records and sharing flags through the Summary Care Record.

Verbatim wording from the response

“NHS SY ICB have previously collaborated with NHSE to develop guidance for practices on how to record on their clinical system records, when a patient has been identified as having drug seeking behaviour. This is then visible to other healthcare services via the Summary Care Record (SCR) and can be used as a flag to healthcare professionals such as Out of Hours services and community pharmacies who may receive requests from patients and”

Source location

Response from NHS South Yorkshire Integrated Care Board
Page 2 · response
Published 8 December 2025

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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

Commission primary-care prescribing incentive schemes requiring opioid patient reviews to prevent avoidable harm.

Verbatim wording from the response

“To support the implementation of this complex work, NHS SY ICB has commissioned prescribing incentive schemes for primary care practices which include the review of patients on opioids to prevent avoidable harm. All three GP practices where the patient was registered have signed up to deliver the scheme for the last 2 years and are achieving above the 90% target.”

Source location

Response from NHS South Yorkshire Integrated Care Board
Page 2 · response
Published 8 December 2025

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 prescribing resources supporting practices to review patients and reduce opioid and co-prescribed opioid-gabapentinoid prescribing where appropriate.

Verbatim wording from the response

“The OSG has developed a suite of prescribing resources to support Practices to review patients and where appropriate reduce the prescribing of opioids and co-prescribed opioids and gabapentinoids.”

Source location

Response from NHS South Yorkshire Integrated Care Board
Page 2 · response
Published 8 December 2025

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

Circulate the reviewed drug-seeking-behaviour guidance to practices through bulletins and the website.

Verbatim wording from the response

“prevent inappropriate prescribing / supply of medicines. We are undertaking a review of the previous guidance and will then circulate to practices, include in bulletins / website.”

Source location

Response from NHS South Yorkshire Integrated Care Board
Page 3 · response
Published 8 December 2025

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

Review of 2022–2025 prescribing data found no outlying opioid-prescribing concerns at the relevant practices.

Verbatim wording from the response

“The ICB must assist NHS England’s (NHSE) controlled drug accountable officer (CDAO) to carry out its functions under the Controlled Drugs (Supervision of Management and Use) Regulations 2013. We have undertaken a further review of the prescribing data provided by NHSE for the practices where the patient was registered covering 2022-2025 which has not identified any outlying concerns for opioid medicines. No incidents relating to controlled drugs have been reported to NHS SY ICB or NHSE”

Source location

Response from NHS South Yorkshire Integrated Care Board
Page 2 · response
Published 8 December 2025

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.6

  1. 1

    Develop a template primary-care prescribing process that practices and prescribers can adopt to support good clinical practice.

    Stated by NHS South Yorkshire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 December 2025.
  2. 2

    Share the Regulation 28 report and response across specified partnership, patient-safety, opioid-safety, mortality, quality and controlled-drug oversight forums to disseminate learning.

    Stated by NHS South Yorkshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 8 December 2025.
  3. 3

    Review the commissioning of pain-management services and consider learning from the case within that review.

    Stated by NHS South Yorkshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2025.
  4. 4

    Convene and lead a multidisciplinary Opioid Safety Group to reduce avoidable opioid harm and high-dose, long-term non-cancer opioid prescribing.

    Stated by NHS South Yorkshire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 December 2025.
  5. 5

    Develop a 2026–2030 South Yorkshire opioid harm-reduction strategy with system-wide goals, aligned partners, prevention commissioning and local delivery arrangements.

    Stated by NHS South Yorkshire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 December 2025.
  6. 6

    Make the template primary-care prescribing process available to all South Yorkshire practices.

    Stated by NHS South Yorkshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 8 December 2025.

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 template primary-care prescribing process that practices and prescribers can adopt to support good clinical practice.

Verbatim wording from the response

“They have also recently developed a template prescribing process for Primary Care that practices/prescribers can adopt and use to support good clinical practice. This will be available to all practices across SY in the next month.”

Source location

Response from NHS South Yorkshire Integrated Care Board
Page 2 · response
Published 8 December 2025

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 the Regulation 28 report and response across specified partnership, patient-safety, opioid-safety, mortality, quality and controlled-drug oversight forums to disseminate learning.

Verbatim wording from the response

“This Regulation 28 report to prevent future deaths and our response will be shared at the following forums, to seek any further opportunities for improvement and ensure lessons are learnt and shared wider than the involved practices:”

Source location

Response from NHS South Yorkshire Integrated Care Board
Page 3 · response
Published 8 December 2025

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 the commissioning of pain-management services and consider learning from the case within that review.

Verbatim wording from the response

“As part of NHS SY ICB transformation, the commissioning of pain management services is currently under review and will consider the learning from this case.”

Source location

Response from NHS South Yorkshire Integrated Care Board
Page 2 · response
Published 8 December 2025

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

Convene and lead a multidisciplinary Opioid Safety Group to reduce avoidable opioid harm and high-dose, long-term non-cancer opioid prescribing.

Verbatim wording from the response

“NHS SY ICB, under its current role, convene and lead a multidisciplinary Opioid Safety Group (OSG) with representatives including GPs, Pain Management Consultants,”

Source location

Response from NHS South Yorkshire Integrated Care Board
Page 1 · response
Published 8 December 2025

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 2026–2030 South Yorkshire opioid harm-reduction strategy with system-wide goals, aligned partners, prevention commissioning and local delivery arrangements.

Verbatim wording from the response

“The OSG has developed a revised strategy for 2026-2030 for South Yorkshire ICS to drive opioid harm reduction by:”

Source location

Response from NHS South Yorkshire Integrated Care Board
Page 2 · response
Published 8 December 2025

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

Make the template primary-care prescribing process available to all South Yorkshire practices.

Verbatim wording from the response

“They have also recently developed a template prescribing process for Primary Care that practices/prescribers can adopt and use to support good clinical practice. This will be available to all practices across SY in the next month.”

Source location

Response from NHS South Yorkshire Integrated Care Board
Page 2 · response
Published 8 December 2025

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