PFD report

Laura Eve PARSONS · Prevention of Future Deaths report

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Issued 3 Sep 2020•County Durham and Darlington

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
0

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 scrutinise repeat prescription requests
    Part of recurring concern: Failure to apply overdose-risk safeguards to medication prescribingPart of recurring concern: Inadequate safeguards against misuse of medicines with abuse potentialPart of recurring concern: Unreliable review and monitoring of repeat prescriptions
  2. Electronic prescribing systems failing to direct prescribers to relevant medical records and the ‘Active Problems’ section
    Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionablePart of recurring concern: Unreliable access to relevant clinical records for safe care
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 scrutinise repeat prescription requests

Wider context from the report

“Ms Parsons was prescribed liquid morphine to treat ‘break through’ pain for cancer. It was first prescribed on 9th August 2019. Ms Parsons was admitted to hospital on 10th August 2019 with an accidental overdose of morphine. It appears 180mls were consumed in a 12 hour period. She recovered and was discharged from hospital. The remainder of the prescribed morphine was discarded. On 31st October 2019 Ms Parsons requested a repeat prescription of liquid morphine from her GP surgery. This was authorised and a 500ml bottle of liquid morphine was dispensed to Ms Parsons. On 5th November 2019 Ms Parsons was found dead due to ingesting a fatal amount of morphine. At inquest evidence was given that information such as recent overdose would be added to the ‘Active Problems’ section on a person’s medical records and would be prominent when any clinician accessed that person’s records. It was explained at inquest that when a patient applies for a repeat prescription so far as the request is within the permitted timescale to issue a repeat of the prescribed item, then the prescription would be issued without any further scrutiny and the electronic systems would not take a prescriber to the patient’s medical records and in particular the ‘Active Problems’ section. ”

Is this part of a recurring concern?

Yes — Failure to apply overdose-risk safeguards to medication prescribing; Inadequate safeguards against misuse of medicines with abuse potential; Unreliable review and monitoring of repeat prescriptions.

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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

Electronic prescribing systems failing to direct prescribers to relevant medical records and the ‘Active Problems’ section

Wider context from the report

“Ms Parsons was prescribed liquid morphine to treat ‘break through’ pain for cancer. It was first prescribed on 9th August 2019. Ms Parsons was admitted to hospital on 10th August 2019 with an accidental overdose of morphine. It appears 180mls were consumed in a 12 hour period. She recovered and was discharged from hospital. The remainder of the prescribed morphine was discarded. On 31st October 2019 Ms Parsons requested a repeat prescription of liquid morphine from her GP surgery. This was authorised and a 500ml bottle of liquid morphine was dispensed to Ms Parsons. On 5th November 2019 Ms Parsons was found dead due to ingesting a fatal amount of morphine. At inquest evidence was given that information such as recent overdose would be added to the ‘Active Problems’ section on a person’s medical records and would be prominent when any clinician accessed that person’s records. It was explained at inquest that when a patient applies for a repeat prescription so far as the request is within the permitted timescale to issue a repeat of the prescribed item, then the prescription would be issued without any further scrutiny and the electronic systems would not take a prescriber to the patient’s medical records and in particular the ‘Active Problems’ section. ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable; Unreliable access to relevant clinical records for safe care.

Open source report

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

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

  1. 1

    Responsibility for ensuring providers maintain a safe controlled-drug management environment rests with the Care Quality Commission.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Responsibility for ensuring providers maintain a safe controlled-drug management environment rests with the Care Quality Commission.

Verbatim wording from the response

“I note that you copied your report to the CQC. As you may be aware, CQC is responsible for making sure that health and social care providers, and other regulators, maintain a safe environment for managing controlled drugs in England.”

Source location

2020-0170-Response-from-Department-for-Health-and-Social-Care_Redacted.pdf
Page 3 · response
Published 10 November 2020

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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