PFD report

Natalie Mortimer · Prevention of Future Deaths report

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Issued 25 Jul 2022•Mid Kent and Medway

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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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 raised3

  1. Failure to update the medical record with hospital discharge information about a previous overdose attempt
  2. Failure to maintain coded overdose alerts in patient records
    Part of recurring concern: Unreliable clinical safety-alert systems
  3. Reliance on default prescription quantities without adequate quantity validation
    Part of recurring concern: Medication quantity controls failing to prevent unsafe access to excessive amounts
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.6

  1. Action

    Introduce a correspondence triage policy and flow chart to route relevant information to appropriate staff.

    Stated by Green Porch Medical CentreStated completedThe respondent said that this action was complete when they made their response on 28 September 2022.
  2. Action

    Add colchicine safety alerts to patient records, recommending quantity limitation and risk assessment for patients with relevant mental-health histories.

    Stated by Green Porch Medical CentreStated completedThe respondent said that this action was complete when they made their response on 28 September 2022.
  3. Action

    Implement patient-record alerts that display relevant safety concerns at login until acknowledged.

    Stated by Green Porch Medical CentreStated completedThe respondent said that this action was complete when they made their response on 28 September 2022.

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 update the medical record with hospital discharge information about a previous overdose attempt

Wider context from the report

“(1) The GP Practice received a discharge note from the hospital for a previous overdose attempt in April 2021. The patient’s medical record was not updated to reflect this information. ”

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 maintain coded overdose alerts in patient records

Wider context from the report

“(2) On the 25th November 2021 the patient attended the GP Practice and the GP on duty reviewed her most recent consultation which took place on the 22nd November 2021 and her records and prescribed the patient with ████████ to be taken 2-4 times a day until symptoms resolve for her gout. The GP detailed in evidence that she issued 100 tablets as this was the default quantity that came up on EMIS. The prescribing doctor stated that there were no alerts coding of a previous overdose in the patients records which may have been a contraindication for issuing a prescription of 100 tablets and therefore relied on the default quantity generated by the system. ”

Is this part of a recurring concern?

Yes — Unreliable clinical safety-alert systems.

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

Reliance on default prescription quantities without adequate quantity validation

Wider context from the report

“(2) On the 25th November 2021 the patient attended the GP Practice and the GP on duty reviewed her most recent consultation which took place on the 22nd November 2021 and her records and prescribed the patient with ████████ to be taken 2-4 times a day until symptoms resolve for her gout. The GP detailed in evidence that she issued 100 tablets as this was the default quantity that came up on EMIS. The prescribing doctor stated that there were no alerts coding of a previous overdose in the patients records which may have been a contraindication for issuing a prescription of 100 tablets and therefore relied on the default quantity generated by the system. ”

Is this part of a recurring concern?

Yes — Medication quantity controls failing to prevent unsafe access to excessive amounts.

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

Introduce a correspondence triage policy and flow chart to route relevant information to appropriate staff.

Verbatim wording from the response

“2. We have introduced a correspondence triage policy/flow chart – please find”

Source location

Response from Green Porch Medical Centre
Page 1 · response
Published 28 September 2022

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 colchicine safety alerts to patient records, recommending quantity limitation and risk assessment for patients with relevant mental-health histories.

Verbatim wording from the response

“6. We have put alerts on patient records for anyone requesting colchicine (see example enclosed) regarding the toxicity to ensure that this is explained to the patient at their next review. The alert recommends limiting the colchicine to 12 tablets and if there is a history of Mental health, depression, Suicide attempt or self-harm, to carry out a risk assessment before issuing.”

Source location

Response from Green Porch Medical Centre
Page 2 · response
Published 28 September 2022

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-record alerts that display relevant safety concerns at login until acknowledged.

Verbatim wording from the response

“3. We now have a system in place to ensure that relevant important alerts are put on the system for individual patients. This will initiate as soon as somebody logs into the records and an alert message will inform the clinician/administration/reception team what the concerns are. This will be on the screen until it is confirmed as acknowledged. Alerts will be in place for overdose attempt/Safeguarding issues/suicidal ideation/domestic violence etc.”

Source location

Response from Green Porch Medical Centre
Page 2 · response
Published 28 September 2022

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

Encourage clinicians to use Arden depression-review templates incorporating self-harm questions and automatic risk alerts.

Verbatim wording from the response

“4. We have encouraged all clinicians to use the Arden templates for reviewing depression. Asking the patient about self-harm is incorporated as part of the template. This will also help to ensure patients safety as it automatically flags up as a red-code. i.e., history of self-harm/suicidal ideation/Overdose attempt etc.”

Source location

Response from Green Porch Medical Centre
Page 2 · response
Published 28 September 2022

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

Employ a full-time read-coder to ensure correspondence is read-coded and necessary patient alerts are added.

Verbatim wording from the response

“We have reviewed this case in depth and have put the following steps in place to ensure that this does not happen in the future.”

Source location

Response from Green Porch Medical Centre
Page 1 · response
Published 28 September 2022

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 Docman for coding, document routing, follow-up completion and escalation of concerns, with audits every three months.

Verbatim wording from the response

“7. We are currently in the process of auditing Docman to ensure quality compliance i.e., read-code is appropriate, that the relevant team has seen the document, any follow ups completed, any concerns raised with the relevant department etc. Audits will be carried out every 3 months, starting 1st of December 2022.”

Source location

Response from Green Porch Medical Centre
Page 2 · response
Published 28 September 2022

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

    Raise the incident internally as a significant event and discuss it at a clinical meeting to support organisational learning.

    Stated by Green Porch Medical CentreStated completedThe respondent said that this action was complete when they made their response on 28 September 2022.
  2. 2

    Deliver refresher training for existing coders and extensive pre-coding training for new coders.

    Stated by Green Porch Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 28 September 2022.

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

Raise the incident internally as a significant event and discuss it at a clinical meeting to support organisational learning.

Verbatim wording from the response

“Thank you for giving us this opportunity to respond. We have learned from this incident and raised this internally has a significant event, as well as raising this with the CCG/ICB to disseminate the message more widely in Kent and beyond. Important changes have been made for the safety of patients in the future as a result of Ms. Mortimer’s death. We hope that this will be of some small consolation to her family in their loss.”

Source location

Response from Green Porch Medical Centre
Page 2 · response
Published 28 September 2022

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

Deliver refresher training for existing coders and extensive pre-coding training for new coders.

Verbatim wording from the response

“1. We have employed a full time read-coder, who will ensure that all letters are properly read-coded and alerts put on patient records when necessary. The Read-coder will have the appropriate training to ensure that this is being maintained to the highest standard. This will ensure that the appropriate letters are sent to the appropriate member of staff. We plan to deliver refresher training to existing coders and all new coders to undergo extensive training prior to coding.”

Source location

Response from Green Porch Medical Centre
Page 1 · response
Published 28 September 2022

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