PFD report

Paul Michael Clark · Prevention of Future Deaths report

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Issued 16 Oct 2024•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.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
6

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 monitor patients with former opioid addiction prescribed opioid painkillers
    Part of recurring concern: Inadequate safeguards against misuse of medicines with abuse potential
  2. Failure to consider the risks of prescribing opioids to patients with former opioid addiction
    Part of recurring concern: Failure to identify clinically significant medication risksPart of recurring concern: Inadequate safeguards against misuse of medicines with abuse potentialPart of recurring concern: Unsafe medication prescribing
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

    Create, disseminate and use a seven-minute briefing based on learning from the Regulation 28 report.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 16 October 2024.
  2. Action

    Deliver opioid-prescribing masterclass training to Stockport GPs and clinicians.

    Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 16 October 2024.
  3. Action

    Publish and maintain continuing professional development updates on opioid use disorder, medicine dependence, withdrawal symptoms and opioid reduction.

    Stated by Royal College of General PractitionersStated completedThe respondent said that this action was complete when they made their response on 16 October 2024.

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 monitor patients with former opioid addiction prescribed opioid painkillers

Wider context from the report

“The inquest heard evidence that Paul Clark had previously been addicted to heroin. He had been successful in treating his opioid addiction and had remained opioid free for many years. His previous problems with opioids and the risks of opioids for him were well documented within his medical notes. However despite the risks opioid painkillers presented to him he had been started in primary care on opioid based painkillers for reported pain. He had become addicted to them and took them at increasing levels topping them up with non-prescribed opioids. There was no evidence before the inquest that the inherent risks of reintroducing opioids to someone who had previously been addicted to them were considered or monitored. It was accepted in evidence that whilst opioid painkillers can be helpful for treating some patients the risks of treating a patient with a former opioid addiction with opioids were significant and that there needed to be a very well thought out rationale with careful monitoring to avoid increasing the chances of a patient relapsing into addiction through GP prescribed medication and that it was essential that GPs considered this when prescribing. ”

Is this part of a recurring concern?

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

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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 consider the risks of prescribing opioids to patients with former opioid addiction

Wider context from the report

“The inquest heard evidence that Paul Clark had previously been addicted to heroin. He had been successful in treating his opioid addiction and had remained opioid free for many years. His previous problems with opioids and the risks of opioids for him were well documented within his medical notes. However despite the risks opioid painkillers presented to him he had been started in primary care on opioid based painkillers for reported pain. He had become addicted to them and took them at increasing levels topping them up with non-prescribed opioids. There was no evidence before the inquest that the inherent risks of reintroducing opioids to someone who had previously been addicted to them were considered or monitored. It was accepted in evidence that whilst opioid painkillers can be helpful for treating some patients the risks of treating a patient with a former opioid addiction with opioids were significant and that there needed to be a very well thought out rationale with careful monitoring to avoid increasing the chances of a patient relapsing into addiction through GP prescribed medication and that it was essential that GPs considered this when prescribing. ”

Is this part of a recurring concern?

Yes — Failure to identify clinically significant medication risks; Inadequate safeguards against misuse of medicines with abuse potential; Unsafe medication prescribing.

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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

Create, disseminate and use a seven-minute briefing based on learning from the Regulation 28 report.

Verbatim wording from the response

“The Regulation 28 report and our response will also be shared, in January 2025, for system learning with the GM cross-sector medicines safety group - the IPMO Medicines Safety Group. This group reports to the Greater Manchester Medicines Management Group (GMMG) and is co-chaired by NHS GM and Manchester University NHS Foundation Trust (MFT). The intention is to reflect on any learning from the Regulation 28 report and create a 7-minute briefing to be produced, disseminated to clinical staff and used for shared learning.”

Source location

Response from GMIC
Page 2 · response
Published 16 October 2024

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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

Deliver opioid-prescribing masterclass training to Stockport GPs and clinicians.

Verbatim wording from the response

“In order to support our wider GP population, a Masterclass presentation on the subject of opioid prescribing was delivered to Stockport GPs and clinicians on 12 September 2024. The session title was ‘Pain Transformation, IMPS and Opioid Stewardship’. A total of 62 clinicians attended the session which was delivered by Dr Thomas Walton, Consultant in Anaesthesia and Pain Management.”

Source location

Response from GMIC
Page 2 · response
Published 16 October 2024

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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

Publish and maintain continuing professional development updates on opioid use disorder, medicine dependence, withdrawal symptoms and opioid reduction.

Verbatim wording from the response

“Continuing Professional Development”

Source location

Response from RCGP
Page 2 · response
Published 16 October 2024

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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

Develop, launch and widely circulate a repeat-prescribing toolkit supporting safer, collaborative prescribing processes and addressing opioid-prescribing safety concerns.

Verbatim wording from the response

“Clinical Policy”

Source location

Response from RCGP
Page 2 · response
Published 16 October 2024

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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.2

  1. 1

    Share the Regulation 28 report and response with the Greater Manchester cross-sector medicines safety group for system learning.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 16 October 2024.
  2. 2

    Hold a national conference on managing addictions in primary care, covering interventions, specialist referral, policy implementation and associated needs.

    Stated by Royal College of General PractitionersStated plannedThe respondent said that this action was planned when they made their response on 16 October 2024.

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 with the Greater Manchester cross-sector medicines safety group for system learning.

Verbatim wording from the response

“The Regulation 28 report and our response will also be shared, in January 2025, for system learning with the GM cross-sector medicines safety group - the IPMO Medicines Safety Group. This group reports to the Greater Manchester Medicines Management Group (GMMG) and is co-chaired by NHS GM and Manchester University NHS Foundation Trust (MFT). The intention is to reflect on any learning from the Regulation 28 report and create a 7-minute briefing to be produced, disseminated to clinical staff and used for shared learning.”

Source location

Response from GMIC
Page 2 · response
Published 16 October 2024

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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

Hold a national conference on managing addictions in primary care, covering interventions, specialist referral, policy implementation and associated needs.

Verbatim wording from the response

“We also provide the forum for GPs who have a particular interest and wish to gain a deeper understanding of the most current evidence, research and practice through Conference activity.”

Source location

Response from RCGP
Page 2 · response
Published 16 October 2024

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