PFD report

Lee Hollman · Prevention of Future Deaths report

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Issued 26 Mar 2014•West Sussex

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
13

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. Lack of an effective system to issue repeat prescriptions
  2. Failure to maintain accurate and up-to-date medical records
    Part of recurring concern: Inadequate recording of medication prescribing decisions
  3. Failure to review patients within their own guidelines for repeat prescriptions
    Part 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.9

  1. Action

    Approve a joint RCGP–Royal Pharmaceutical Society statement setting out guidelines for good working relationships between GPs and pharmacists.

    Stated by Royal College of General PractitionersStated completedThe respondent said that this action was complete when they made their response on 26 March 2014.
  2. Action

    Continue holding specific mental-health reviews and reviewing patients through specialist correspondence, case meetings, and face-to-face consultations.

    Stated by Riverside SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2014.
  3. Action

    Update the clinical IT system to reinforce the revised repeat-prescribing policy and reduce medication-processing errors.

    Stated by Riverside SurgeryStated completedThe respondent said that this action was complete when they made their response on 26 March 2014.

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

Lack of an effective system to issue repeat prescriptions

Wider context from the report

“4. The lack of an effective system to issue repeat prescriptions ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 accurate and up-to-date medical records

Wider context from the report

“1. Failure to maintain sufficiently accurate and updated medical records 2. Failure to remove Trazodone from the repeat prescription record 3. Failure to delete the ‘old’ dosage of Quetiapine from the relevant medical records ”

Is this part of a recurring concern?

Yes — Inadequate recording of medication prescribing decisions.

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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 patients within their own guidelines for repeat prescriptions

Wider context from the report

“5. Failure to review patients within their own guidelines with regard to repeat prescriptions ”

Is this part of a recurring concern?

Yes — 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

Approve a joint RCGP–Royal Pharmaceutical Society statement setting out guidelines for good working relationships between GPs and pharmacists.

Verbatim wording from the response

“The tragic death of Lee Hollman highlights the need for GPs and Pharmacists to work closely together.”

Source location

2014-0135-Response-by-Royal-College-of-General-Practitioners
Page 3 · response
Published 26 March 2014

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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

Continue holding specific mental-health reviews and reviewing patients through specialist correspondence, case meetings, and face-to-face consultations.

Verbatim wording from the response

“Throughout the year the GP’s have and continue to hold specific Mental Health Reviews. In the most recent Quality Outcome Framework (QOF - 2013/2014) review of our clinical records confirmed that reviews were being carried out in accordance with the relevant guidelines.”

Source location

2014-0135-Response-by-Riverside-Surgery
Page 5 · response
Published 26 March 2014

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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

Update the clinical IT system to reinforce the revised repeat-prescribing policy and reduce medication-processing errors.

Verbatim wording from the response

“2. We have updated the IT system to reinforce the policy. To illustrate this, I enclose screen shots showing the stages of the issuing process. The intention of this change is to reduce the risk of human error.”

Source location

2014-0135-Response-by-Riverside-Surgery
Page 4 · response
Published 26 March 2014

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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

Allocate repeat-prescription signing to the issuing GP rather than the duty doctor.

Verbatim wording from the response

“The coroner raised particular concerns regarding the Duty Doctor having to sign all the repeat prescriptions for a particular day. We have subsequently reviewed this practice and now have allocated the signing of prescriptions to the issuing GP, who is likely to be more familiar with the patient and their medication. The significantly reduces the number of prescriptions that each GP will sign on any given day by 66-80% (based on 3-4 GPs on duty).”

Source location

2014-0135-Response-by-Riverside-Surgery
Page 5 · response
Published 26 March 2014

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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

Staple prescriptions spanning multiple sheets together so all medication doses remain visible during signing review.

Verbatim wording from the response

“Prescriptions that run onto multiple sheets will be stapled together, so to avoid being separated. This is important for ensuring that multiple doses of the same medication are visible for review when signing.”

Source location

2014-0135-Response-by-Riverside-Surgery
Page 5 · response
Published 26 March 2014

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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

Require CMHT correspondence before changing medication, record medication changes, and prompt GPs to reconcile surgery and CMHT medication lists.

Verbatim wording from the response

“The medication prescribing process for patients under the care of the CMHT has been revised in the following key respects:”

Source location

2014-0135-Response-by-Riverside-Surgery
Page 3 · response
Published 26 March 2014

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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

Limit psychotropic medication issues to one month and require GP re-issue and review against current CMHT correspondence before further supply.

Verbatim wording from the response

“The key aspects of the new procedure are as follows:”

Source location

2014-0135-Response-by-Riverside-Surgery
Page 4 · response
Published 26 March 2014

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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

Rewrite the repeat prescribing policy for psychotropic medications and require an additional prescribing-doctor review to confirm dose and reduce harm.

Verbatim wording from the response

“As a surgery we are keen to learn from this tragic event and have reflected at great length on the medication errors which occurred. The policy for the issuing of repeat medications has been reviewed and re-written, particularly in respect to psychotropic medications. I enclose the new policy for your review.”

Source location

2014-0135-Response-by-Riverside-Surgery
Page 2 · response
Published 26 March 2014

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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

Disseminate the revised repeat-prescribing protocol to all clinical and administrative staff.

Verbatim wording from the response

“The revised repeat prescribing protocol addresses concerns about the issuing of the repeat prescriptions. This has been disseminated to all clinical and administrative staff, with a change in the Clinical IT system functioning to support the correct implementation of this policy.”

Source location

2014-0135-Response-by-Riverside-Surgery
Page 5 · response
Published 26 March 2014

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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

    Bring together an invited multi-stakeholder group to explore the joint statement’s recommendations and identify required actions.

    Stated by Royal College of General PractitionersStated plannedThe respondent said that this action was planned when they made their response on 26 March 2014.
  2. 2

    Work with the Royal Pharmaceutical Society to explore continuing opportunities for joint learning between GPs and pharmacists.

    Stated by Royal College of General PractitionersStated plannedThe respondent said that this action was planned when they made their response on 26 March 2014.
  3. 3

    Set up a joint working group including patients and service users to advance an agreed work programme.

    Stated by Royal College of General PractitionersStated plannedThe respondent said that this action was planned when they made their response on 26 March 2014.
  4. 4

    Increase communication and collaborative working with the CMHT through liaison meetings and further discussions about mental-health prescribing and information sharing.

    Stated by Riverside SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2014.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Commenting on an individual GP’s performance is outside the College’s remit; it can provide only training and member advice.

    Stated by Royal College of General PractitionersOutside remitThe respondent said that this matter was outside its role or authority.

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

Bring together an invited multi-stakeholder group to explore the joint statement’s recommendations and identify required actions.

Verbatim wording from the response

“Moving forward”

Source location

2014-0135-Response-by-Royal-College-of-General-Practitioners
Page 10 · response
Published 26 March 2014

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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

Work with the Royal Pharmaceutical Society to explore continuing opportunities for joint learning between GPs and pharmacists.

Verbatim wording from the response

“Education and training”

Source location

2014-0135-Response-by-Royal-College-of-General-Practitioners
Page 10 · response
Published 26 March 2014

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

Set up a joint working group including patients and service users to advance an agreed work programme.

Verbatim wording from the response

“Moving forward”

Source location

2014-0135-Response-by-Royal-College-of-General-Practitioners
Page 10 · response
Published 26 March 2014

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 communication and collaborative working with the CMHT through liaison meetings and further discussions about mental-health prescribing and information sharing.

Verbatim wording from the response

“Increasing our communication and collaborative working with the CMHT is ongoing. Increasing the number of steps in the issuing of mental health medications produces a higher number of reviews of the patient record and their medications by the GP.”

Source location

2014-0135-Response-by-Riverside-Surgery
Page 5 · response
Published 26 March 2014

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

Commenting on an individual GP’s performance is outside the College’s remit; it can provide only training and member advice.

Verbatim wording from the response

“Similarly, it is not for us to comment on the performance of any individual GP and the information set out below is solely to show you what we do in the context of training and advice to our Members.”

Source location

2014-0135-Response-by-Royal-College-of-General-Practitioners
Page 1 · response
Published 26 March 2014

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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