PFD report

Clive Miles · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 16 Dec 2019•Manchester South

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

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 raised1

  1. Failure to adequately assess overdose risk before changing prescription frequency
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.1

  1. Action

    Remind all Stockport GPs to record clear, detailed reasons and factors supporting changes to prescribing frequency.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 31 December 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The decision to change prescribing frequency rests on the treating clinician’s judgement at the consultation.

    Stated by NHS Greater Manchester Integrated Care BoardRedirects 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 adequately assess overdose risk before changing prescription frequency

Wider context from the report

“The inquest was told that previously Clive Miles had been changed to weekly prescriptions because he had overdosed on prescribed medication when on monthly prescriptions. In the week before his death his General Practitioner had moved him back to monthly prescribing believing that the risk no longer existed based on a discussion with him about how he was at that time. There was limited evidence of any assessment of the risk or the need to change the prescribing pattern. As a result he was in possession of a significantly increased quantity of medication in comparison to the amount he had been restricted to on weekly prescriptions. ”

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

Remind all Stockport GPs to record clear, detailed reasons and factors supporting changes to prescribing frequency.

Verbatim wording from the response

“Stockport CCG is committed to learning and with this case in mind I will ensure that all GPs across the Stockport patch are reminded of the importance of recording clear and detailed notes explaining the basis on which any change to prescribing frequency has been made.”

Source location

2019-0432-Response-from-NHS-Stockport-Clinical-Commissioning-Group
Page 2 · response
Published 31 December 2019

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

The decision to change prescribing frequency rests on the treating clinician’s judgement at the consultation.

Verbatim wording from the response

“The decision to amend the frequency of prescribing is based on the clinician’s judgement at the time of the consultation. Unfortunately, there is no standard risk assessment tool that is currently evidenced to be effective. The tools that are available are either not specific enough or not sensitive enough. This essentially means that assessment of risk is a clinical”

Source location

2019-0432-Response-from-NHS-Stockport-Clinical-Commissioning-Group
Page 1 · response
Published 31 December 2019

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

No standard risk assessment tool can be adopted because available tools lack sufficient specificity or sensitivity and are not evidenced as effective.

Verbatim wording from the response

“The decision to amend the frequency of prescribing is based on the clinician’s judgement at the time of the consultation. Unfortunately, there is no standard risk assessment tool that is currently evidenced to be effective. The tools that are available are either not specific enough or not sensitive enough. This essentially means that assessment of risk is a clinical”

Source location

2019-0432-Response-from-NHS-Stockport-Clinical-Commissioning-Group
Page 1 · response
Published 31 December 2019

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