PFD report

Karen Moran · Prevention of Future Deaths report

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Issued 22 Nov 2018•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
1

Named on the report

Responses found
0

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

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Concerns raised2

  1. Prescribing patterns allowing access to significant amounts of prescribed medication
    Part of recurring concern: Medication quantity controls failing to prevent unsafe access to excessive amounts
  2. Failure to refer patients with recognised addiction to prescribed medication for addiction support
    Part of recurring concern: Unreliable access to appropriate addiction support
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

Prescribing patterns allowing access to significant amounts of prescribed medication

Wider context from the report

“She had a long term addiction to prescribed medication that had been recognised. Medication continued to be prescribed on repeat prescriptions with no referral to address the addiction. The prescribing pattern meant she had access to significant amounts of prescribed medication. ”

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 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 refer patients with recognised addiction to prescribed medication for addiction support

Wider context from the report

“She had a long term addiction to prescribed medication that had been recognised. Medication continued to be prescribed on repeat prescriptions with no referral to address the addiction. The prescribing pattern meant she had access to significant amounts of prescribed medication. ”

Is this part of a recurring concern?

Yes — Unreliable access to appropriate addiction support.

Open source report
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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