PFD report

Dayle BATES · Prevention of Future Deaths report

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Issued 8 Feb 2024•Cumbria

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
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. Lack of a direct pharmacy-to-provider means for reporting stopped methadone collection
    Part of recurring concern: Failure to provide timely clinical follow-up after medication prescribing
  2. Lack of an obligation on pharmacies to report wider service-user welfare concerns
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.1

  1. Action

    Communicate accurate contact information, including telephone numbers and secure email addresses, to all Community Pharmacies.

    Stated by WaythroughStated completedThe respondent said that this action was complete when they made their response on 21 February 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

Lack of a direct pharmacy-to-provider means for reporting stopped methadone collection

Wider context from the report

“(1) Mr Bates had a prescription for methadone issued by Recovery Steps. He was required to collect a dose each day from a named pharmacy. On 14th July 2023 Mr Bates stopped collecting methadone. The pharmacy explained that they sought to inform Recovery Steps of this development shortly after 14th but did not have any contact details other than a general number which is not always answered and a direct line for one key worker. They attempted to raise their concerns with that key worker, but the message appears not to have been relayed, Recovery Steps did not become aware that Mr Bate was not collecting methadone until 30th August 2023. In answer to question from the Court, the pharmacy have also indicated that although it is there practice to inform Recovery Steps of any other concerns they might have about a person prescribed with Methadone, this is a voluntary decision on their part and not a matter that arises from any obligation. I am concerned that this situation gives rise to a risk of future death. It appears that there is no direct means by which a pharmacy can report to Recovery Steps that a service user has stopped collecting methadone. There is also no apparent obligation on pharmacies to report wider concerns for services users' welfare to Recovery Steps. In each case this may mean that Recovery Steps are unaware that vulnerable service users require additional support. ”

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 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

Lack of an obligation on pharmacies to report wider service-user welfare concerns

Wider context from the report

“(1) Mr Bates had a prescription for methadone issued by Recovery Steps. He was required to collect a dose each day from a named pharmacy. On 14th July 2023 Mr Bates stopped collecting methadone. The pharmacy explained that they sought to inform Recovery Steps of this development shortly after 14th but did not have any contact details other than a general number which is not always answered and a direct line for one key worker. They attempted to raise their concerns with that key worker, but the message appears not to have been relayed, Recovery Steps did not become aware that Mr Bate was not collecting methadone until 30th August 2023. In answer to question from the Court, the pharmacy have also indicated that although it is there practice to inform Recovery Steps of any other concerns they might have about a person prescribed with Methadone, this is a voluntary decision on their part and not a matter that arises from any obligation. I am concerned that this situation gives rise to a risk of future death. It appears that there is no direct means by which a pharmacy can report to Recovery Steps that a service user has stopped collecting methadone. There is also no apparent obligation on pharmacies to report wider concerns for services users' welfare to Recovery Steps. In each case this may mean that Recovery Steps are unaware that vulnerable service users require additional support. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Communicate accurate contact information, including telephone numbers and secure email addresses, to all Community Pharmacies.

Verbatim wording from the response

“For assurance, in light of your findings, Humankind has undertaken a targeted piece of work to address and reduce risk in the hope that future deaths are prevented, this work includes:”

Source location

Response from Recovery Steps Cumbria
Page 3 · response
Published 21 February 2024

Open published response

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.5

  1. 1

    Communicate accurate phone-call record-keeping and information-sharing requirements to staff and include them in record-keeping training.

    Stated by WaythroughStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
  2. 2

    Inform medicines optimisation leads from both Cumbria Integrated Care Boards about the issue to support coordinated services.

    Stated by WaythroughStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
  3. 3

    Communicate with all Shared Care services to check whether approved Home Office prescription wording is included.

    Stated by WaythroughStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
  4. 4

    Communicate with the North and South Cumbria Pharmaceutical Committees about the identified issue.

    Stated by WaythroughStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
  5. 5

    Inform all Community Pharmacies of their obligations when dispensing Opioid Substitution Treatment.

    Stated by WaythroughStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The shared-care GP, not Recovery Steps Cumbria, owned the prescription and was responsible for managing the medication.

    Stated by WaythroughRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    The Community Pharmacy’s comments about pharmacist liaison with prescribers for controlled medication were inaccurate.

    Stated by WaythroughDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Communicate accurate phone-call record-keeping and information-sharing requirements to staff and include them in record-keeping training.

Verbatim wording from the response

“Although Recovery Steps has found no evidence that a call was received, or that a named worker was contacted by the Community Pharmacy, the service has communicated with all staff the importance of accurate record keeping and information sharing following all phone calls received. This has also been included in Recovery Steps Cumbria’s record keeping training.”

Source location

Response from Recovery Steps Cumbria
Page 2 · response
Published 21 February 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

Inform medicines optimisation leads from both Cumbria Integrated Care Boards about the issue to support coordinated services.

Verbatim wording from the response

“For assurance, in light of your findings, Humankind has undertaken a targeted piece of work to address and reduce risk in the hope that future deaths are prevented, this work includes:”

Source location

Response from Recovery Steps Cumbria
Page 3 · response
Published 21 February 2024

Open published response

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

Communicate with all Shared Care services to check whether approved Home Office prescription wording is included.

Verbatim wording from the response

“For assurance, in light of your findings, Humankind has undertaken a targeted piece of work to address and reduce risk in the hope that future deaths are prevented, this work includes:”

Source location

Response from Recovery Steps Cumbria
Page 3 · response
Published 21 February 2024

Open published response

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

Communicate with the North and South Cumbria Pharmaceutical Committees about the identified issue.

Verbatim wording from the response

“For assurance, in light of your findings, Humankind has undertaken a targeted piece of work to address and reduce risk in the hope that future deaths are prevented, this work includes:”

Source location

Response from Recovery Steps Cumbria
Page 3 · response
Published 21 February 2024

Open published response

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

Inform all Community Pharmacies of their obligations when dispensing Opioid Substitution Treatment.

Verbatim wording from the response

“For assurance, in light of your findings, Humankind has undertaken a targeted piece of work to address and reduce risk in the hope that future deaths are prevented, this work includes:”

Source location

Response from Recovery Steps Cumbria
Page 3 · response
Published 21 February 2024

Open published response

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

The shared-care GP, not Recovery Steps Cumbria, owned the prescription and was responsible for managing the medication.

Verbatim wording from the response

“It is stated within your findings that Recovery Steps Cumbria issued Mr Bates with a methadone prescription, to clarify Mr Bates’ care was managed under Shared Care, which means that he was provided with Opioid Substitutive Treatment (OST) via his General Practitioner, with Recovery Steps Cumbria working in partnership with the GP to deliver psychosocial interventions. In this instance the prescriber was from James St Surgery in Workington, and it is the GP surgery who owns the prescription and is responsible for the management of medication in Mr Bates’ case.”

Source location

Response from Recovery Steps Cumbria
Page 1 · response
Published 21 February 2024

Open published response

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

The Community Pharmacy’s comments about pharmacist liaison with prescribers for controlled medication were inaccurate.

Verbatim wording from the response

“With regards to the comments made by the Community Pharmacy, they are inaccurate. There is a duty upon Pharmacists with regards to liaison with prescribers for controlled medication as set out in their Medicines, Ethics and Practice Guidance (MEP). The actual wording from the MEP Guidance is: “If you know a patient has missed three days’ prescribed treatment (or the number of days defined by any local agreement with the prescriber), there is a risk that they will have lost tolerance to the drug and the usual dose may cause overdose. In the best interests of the patient, consider contacting the prescriber to discuss appropriate next steps.” MEP Section 3.6.7 Prescription requirements for Schedule 2 and 3 Controlled Drugs.”

Source location

Response from Recovery Steps Cumbria
Page 1 · response
Published 21 February 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