PFD report

Philip Richard David BREATNACH · Prevention of Future Deaths report

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Issued 15 Sep 2016•Brighton and Hove

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.

View original report
Concerns
8

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
8

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 raised8

  1. Excessive quantities of Dihydrocodeine prescribed
    Part of recurring concern: Medication quantity controls failing to prevent unsafe access to excessive amountsPart of recurring concern: Unsafe medication prescribing
  2. Unrestricted online applications for medications
  3. Prescribing Dihydrocodeine for migraine
    Part of recurring concern: Unsafe 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.1

  1. Action

    Work with partner agencies to consolidate regulatory and professional guidance on online prescribing and medicine supply.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 18 September 2016.

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

Excessive quantities of Dihydrocodeine prescribed

Wider context from the report

“(1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ”

Is this part of a recurring concern?

Yes — Medication quantity controls failing to prevent unsafe access to excessive amounts; Unsafe medication prescribing.

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

Unrestricted online applications for medications

Wider context from the report

“(1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Prescribing Dihydrocodeine for migraine

Wider context from the report

“(1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

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 prescribe safe Dihydrocodeine dosing instructions

Wider context from the report

“(1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

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 contact the patient’s GP to verify medication application answers

Wider context from the report

“(1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ”

Is this part of a recurring concern?

Yes — Failure to reliably escalate patient safety concerns to primary care.

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 account for the potential diversion of Dihydrocodeine

Wider context from the report

“(1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

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 thoroughly check online medication application forms

Wider context from the report

“(1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ”

Is this part of a recurring concern?

Yes — Failure to verify patient suitability before online sale of restricted medicines.

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 assess a patient in person before prescribing Dihydrocodeine

Wider context from the report

“(1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

Open source report

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 partner agencies to consolidate regulatory and professional guidance on online prescribing and medicine supply.

Verbatim wording from the response

“The group agreed to work together to assimilate current regulatory and professional guidance into one place so there is greater clarity regarding good practice in respect of online prescribing and supply of medicines giving particular guidance on medicines such as controlled drugs and antibiotics.”

Source location

2016-0330-Response-by-NHS-England
Page 2 · response
Published 18 September 2016

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.7

  1. 1

    Work with other agencies to develop measures protecting vulnerable patients from future harm.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 18 September 2016.
  2. 2

    Share case intelligence with relevant regulatory and professional agencies.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 September 2016.
  3. 3

    Include General Practitioner advice on Special Patient Notes in the Pharmacy Urgent Medicines Supply service materials.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 18 September 2016.
  4. 4

    Host a multiagency meeting to discuss online prescribing and controlled-drug safety concerns.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 September 2016.
  5. 5

    Use learning from the case to inform NHS England’s Digital Strategy.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 18 September 2016.
  6. 6

    Continue discussing the Coroner’s concerns and develop prevention strategies with responsible agencies.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 18 September 2016.
  7. 7

    Raise case-related controlled-drug prescribing issues through the CQC National Controlled Drugs Group.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 18 September 2016.

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 other agencies to develop measures protecting vulnerable patients from future harm.

Verbatim wording from the response

“Agencies also shared intelligence on this case. Regulators agreed to work together further to look at protecting vulnerable patients in future.”

Source location

2016-0330-Response-by-NHS-England
Page 2 · response
Published 18 September 2016

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

Share case intelligence with relevant regulatory and professional agencies.

Verbatim wording from the response

“Agencies also shared intelligence on this case. Regulators agreed to work together further to look at protecting vulnerable patients in future.”

Source location

2016-0330-Response-by-NHS-England
Page 2 · response
Published 18 September 2016

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

Include General Practitioner advice on Special Patient Notes in the Pharmacy Urgent Medicines Supply service materials.

Verbatim wording from the response

“NHS England will use this learning to inform its Digital Strategy. We will also include advice to General Practitioners about Special Patient Notes, which are used within the integrated urgent care software so alerts can be set up for NHS 111 call handlers and out of hours general practitioners when they access a particular patient record as part of the Pharmacy Urgent Medicines Supply service being introduced from 1st December 2016.”

Source location

2016-0330-Response-by-NHS-England
Page 2 · response
Published 18 September 2016

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

Host a multiagency meeting to discuss online prescribing and controlled-drug safety concerns.

Verbatim wording from the response

“As noted in my letter of 27th July 2016, NHS England has, what may be termed, a “systems oversight” role for the safe use of controlled drugs (including dihydrocodeine) under the Controlled Drugs (Supervision and Management of Use) Regulations 2013. We raised the issues arising from this case at the Care Quality Commission National Controlled Drugs Group on 14th June 2016 and hosted a multiagency meeting to discuss these issues further on 2nd November 2016. Representatives from the Police Force, Care Quality Commission, Department of Health, General Medical Council, General Pharmaceutical Council, Medicines and Healthcare products Regulatory Agency, NHS England, NHS Improvement and the British Medical Association General Practitioners”

Source location

2016-0330-Response-by-NHS-England
Page 1 · response
Published 18 September 2016

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

Use learning from the case to inform NHS England’s Digital Strategy.

Verbatim wording from the response

“NHS England will use this learning to inform its Digital Strategy. We will also include advice to General Practitioners about Special Patient Notes, which are used within the integrated urgent care software so alerts can be set up for NHS 111 call handlers and out of hours general practitioners when they access a particular patient record as part of the Pharmacy Urgent Medicines Supply service being introduced from 1st December 2016.”

Source location

2016-0330-Response-by-NHS-England
Page 2 · response
Published 18 September 2016

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

Continue discussing the Coroner’s concerns and develop prevention strategies with responsible agencies.

Verbatim wording from the response

“We will continue to discuss the Coroner’s concerns and endeavour to develop strategies in partnership with other responsible agencies aimed at preventing future deaths.”

Source location

2016-0330-Response-by-NHS-England
Page 2 · response
Published 18 September 2016

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

Raise case-related controlled-drug prescribing issues through the CQC National Controlled Drugs Group.

Verbatim wording from the response

“As noted in my letter of 27th July 2016, NHS England has, what may be termed, a “systems oversight” role for the safe use of controlled drugs (including dihydrocodeine) under the Controlled Drugs (Supervision and Management of Use) Regulations 2013. We raised the issues arising from this case at the Care Quality Commission National Controlled Drugs Group on 14th June 2016 and hosted a multiagency meeting to discuss these issues further on 2nd November 2016. Representatives from the Police Force, Care Quality Commission, Department of Health, General Medical Council, General Pharmaceutical Council, Medicines and Healthcare products Regulatory Agency, NHS England, NHS Improvement and the British Medical Association General Practitioners”

Source location

2016-0330-Response-by-NHS-England
Page 1 · response
Published 18 September 2016

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