PFD report

Daniel Young · Prevention of Future Deaths report

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Issued 26 Jul 2018•Inner West London

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
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

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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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
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.3

  1. Action

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

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 23 September 2018.
  2. Action

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

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 23 September 2018.
  3. Action

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

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 23 September 2018.

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

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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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

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

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 23 September 2018.
  2. 2

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

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2018.

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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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