Daniel Young · Prevention of Future Deaths report

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Issued 26 Jul 2018•Inner West London

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

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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Report evidence summary

Concerns raised1

  1. Failure of GP surgeries to routinely monitor psychiatric patients’ collection of antipsychotic medication
    Part of recurring concern: Failure to provide timely clinical follow-up after medication prescribing

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Department of Health and Social Care

    Explore with NHS Digital opportunities for primary care systems to alert GPs about prescription collection issues for named patients and drugs.

  2. Department of Health and Social Care

    Work with NHS Improvement on provider communications about making discharge letters explicit on medication risks requiring primary-care monitoring.

  3. Department of Health and Social Care

    Develop a community mental health services framework covering joint working, care coordination, transitions, medication optimisation, staff competencies and discharge processes.

  4. Department of Health and Social Care

    Ask GP practices to consider mechanisms for monitoring collection of antipsychotic medication prescriptions.

  5. Department of Health and Social Care

    Write to GP practices about monitoring collection of antipsychotic medication prescriptions.

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 of GP surgeries to routinely monitor psychiatric patients’ collection of antipsychotic medication

Wider context from the report

“2. GP surgeries do not routinely monitor that psychiatric patients are collecting their antipsychotics. Evidence revealed that it is not uncommon for such patients to stop their medication and relapse. Relapse puts them at a risk of harm to themselves and, sometimes, they pose a risk to others. ”

Is this part of a recurring concern?

Yes — Failure to provide timely clinical follow-up after 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

Explore with NHS Digital opportunities for primary care systems to alert GPs about prescription collection issues for named patients and drugs.

Verbatim wording from the response

“• NHS England will explore with NHS Digital what opportunities there are for primary care clinical systems to alert GPs around prescription collection issues for named patients and named drugs; and”

Source location

2018-0240-Response-by-Department-of-Health-Social-Care
Page 2 · response
Published 23 September 2018

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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 NHS Improvement on provider communications about making discharge letters explicit on medication risks requiring primary-care monitoring.

Verbatim wording from the response

“• NHS England will work with NHS Improvement on a communication to providers around making discharge letters explicit on medication risks that need to be monitored in primary care.”

Source location

2018-0240-Response-by-Department-of-Health-Social-Care
Page 2 · response
Published 23 September 2018

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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 a community mental health services framework covering joint working, care coordination, transitions, medication optimisation, staff competencies and discharge processes.

Verbatim wording from the response

“You will be interested to know that NHS England is currently developing a framework for community mental health services which will articulate models of improved joint working between primary and secondary mental health services in community settings.”

Source location

2018-0240-Response-by-Department-of-Health-Social-Care
Page 1 · response
Published 23 September 2018

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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

Ask GP practices to consider mechanisms for monitoring collection of antipsychotic medication prescriptions.

Verbatim wording from the response

“• NHS England will write to GP practices to make them aware of this issue and to consider what mechanism they do or could employ to monitor the collection of antipsychotic medication prescriptions;”

Source location

2018-0240-Response-by-Department-of-Health-Social-Care
Page 2 · response
Published 23 September 2018

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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

Write to GP practices about monitoring collection of antipsychotic medication prescriptions.

Verbatim wording from the response

“In the interim, NHS England has confirmed that it will undertake the following actions by the end of the year to address the issues noted in your report:”

Source location

2018-0240-Response-by-Department-of-Health-Social-Care
Page 2 · response
Published 23 September 2018

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
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Data last updated 7 September 2026