PFD report

Lilian Margaret BOARD · Prevention of Future Deaths report

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Issued 5 Oct 2023•Lincolnshire

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
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 raised1

  1. Failure to prevent duplicate medication prescriptions between hospital and GP
    Part of recurring concern: Failure to prevent duplicate or discontinued medication prescriptionsPart of recurring concern: Unreliable doctor-to-doctor coordination of prescribing
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The Trust’s 14-day discharge-supply policy and associated arrangements remain appropriate despite accepted overlapping prescriptions.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 prevent duplicate medication prescriptions between hospital and GP

Wider context from the report

“The deceased was prescribed ████████ by her GP. Following discharge from hospital on 18th January 2023 LCH also prescribed ████████. The deceased therefore had two prescriptions of the same medication that she used to end her life. Are there any checks in place to avoid duplicity of prescriptions between hospital and GP ? ”

Is this part of a recurring concern?

Yes — Failure to prevent duplicate or discontinued medication prescriptions; Unreliable doctor-to-doctor coordination of prescribing.

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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 Trust’s 14-day discharge-supply policy and associated arrangements remain appropriate despite accepted overlapping prescriptions.

Verbatim wording from the response

“It is important to point out that the policy of the Trust (Policy for Medicines Management Supply of Medicines), in agreement with Lincolnshire Primary Care colleagues including the Primary Care Networks, the Local Medical Committee and the Integrated Care Board, is that we supply patients with 14 days supply of medication as a default at the point of discharge, This is not unusual, as almost all acute provider Trusts within NHS England have similar policies to dispense medication supplies upon discharge, with these supply arrangements ranging anywhere between 7-28 days depending on policies of the specific NHS Trusts.”

Source location

Response from United Lincolnshire Hospitals NHS Trust
Page 1 · response
Published 18 October 2023

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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 positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The additional hospital supply was not necessary to explain the overdose, as the patient’s pre-existing tablets alone were likely fatal.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 additional hospital supply was not necessary to explain the overdose, as the patient’s pre-existing tablets alone were likely fatal.

Verbatim wording from the response

“I note that in Mrs Board’s case, it is estimated that she took approximately ████████ tablets, so even if ULHT had not discharged her with a further 14 day supply, that estimate implies that she would have still had a minimum of ████████ tablets in her possession not dispensed by our Trust, which would in itself have been a likely fatal dose in overdose.”

Source location

Response from United Lincolnshire Hospitals NHS Trust
Page 2 · response
Published 18 October 2023

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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