PFD report

Debra BATES · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 28 Jun 2024•Derby and Derbyshire

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to limit prescription quantities to an appropriate 3- or 4-day supply
    Part of recurring concern: Medication quantity controls failing to prevent unsafe access to excessive amounts
  2. Failure to investigate safe implementation of short-cycle prescribing and available computer safety measures
  3. Failure to prevent or minimise incorrect prescription-duration selection
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.5

  1. Action

    Implement and circulate a standard operating procedure for safely managing three- and four-day prescriptions, including clinician-only issuing, scheduling, alerts, coding and regular review.

    Stated by Park SurgeryStated completedThe respondent said that this action was complete when they made their response on 4 July 2024.
  2. Action

    Review the three- and four-day prescribing SOP in July 2025.

    Stated by Park SurgeryStated plannedThe respondent said that this action was planned when they made their response on 4 July 2024.
  3. Action

    Consult local practices and the ICB prescribing team about managing frequent prescriptions and incorporate relevant learning into the practice SOP.

    Stated by Park SurgeryStated completedThe respondent said that this action was complete when they made their response on 4 July 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

Failure to limit prescription quantities to an appropriate 3- or 4-day supply

Wider context from the report

“A recommendation had been made by ████████, Consultant Psychiatrist for regular prescriptions to be supplied (blisters) on a 3 days followed by a 4 days cycle. This would limit the amount of prescription medication available to her at anyone time. Debra Bates had a chaotic prescription pill use which appears to be fuelling her turbulence The dispensing pharmacist said that non blister pack 3 and 4 day prescription can be facilitated. These could be post dated to be collected on Tuesdays and Fridays for example. A task was sent to the practice pharmacist to discuss the case. The response was that 3 and 4 day prescriptions could cause confusion as double items would need to be added to the repeat prescription for each duration. This would result in more frequent deliveries and could cause issues. The regular prescriptions continued to be issued weekly (7 days) In evidence ████████ said there would be a risk of over prescribing because by mistake a request for a 4 day prescription would be selected on the computer screen rather than a 3 day No further investigation or inquiries were made as to how other practices implemented this prescribing approach in a case where there are multiple medications (including controlled drugs) or whether / what safety measures are available on the computer system, to prevent / minimise the risk of the wrong prescription being requested ”

Is this part of a recurring concern?

Yes — Medication quantity controls failing to prevent unsafe access to excessive amounts.

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 investigate safe implementation of short-cycle prescribing and available computer safety measures

Wider context from the report

“A recommendation had been made by ████████, Consultant Psychiatrist for regular prescriptions to be supplied (blisters) on a 3 days followed by a 4 days cycle. This would limit the amount of prescription medication available to her at anyone time. Debra Bates had a chaotic prescription pill use which appears to be fuelling her turbulence The dispensing pharmacist said that non blister pack 3 and 4 day prescription can be facilitated. These could be post dated to be collected on Tuesdays and Fridays for example. A task was sent to the practice pharmacist to discuss the case. The response was that 3 and 4 day prescriptions could cause confusion as double items would need to be added to the repeat prescription for each duration. This would result in more frequent deliveries and could cause issues. The regular prescriptions continued to be issued weekly (7 days) In evidence ████████ said there would be a risk of over prescribing because by mistake a request for a 4 day prescription would be selected on the computer screen rather than a 3 day No further investigation or inquiries were made as to how other practices implemented this prescribing approach in a case where there are multiple medications (including controlled drugs) or whether / what safety measures are available on the computer system, to prevent / minimise the risk of the wrong prescription being requested ”

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

Failure to prevent or minimise incorrect prescription-duration selection

Wider context from the report

“A recommendation had been made by ████████, Consultant Psychiatrist for regular prescriptions to be supplied (blisters) on a 3 days followed by a 4 days cycle. This would limit the amount of prescription medication available to her at anyone time. Debra Bates had a chaotic prescription pill use which appears to be fuelling her turbulence The dispensing pharmacist said that non blister pack 3 and 4 day prescription can be facilitated. These could be post dated to be collected on Tuesdays and Fridays for example. A task was sent to the practice pharmacist to discuss the case. The response was that 3 and 4 day prescriptions could cause confusion as double items would need to be added to the repeat prescription for each duration. This would result in more frequent deliveries and could cause issues. The regular prescriptions continued to be issued weekly (7 days) In evidence ████████ said there would be a risk of over prescribing because by mistake a request for a 4 day prescription would be selected on the computer screen rather than a 3 day No further investigation or inquiries were made as to how other practices implemented this prescribing approach in a case where there are multiple medications (including controlled drugs) or whether / what safety measures are available on the computer system, to prevent / minimise the risk of the wrong prescription being requested ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Implement and circulate a standard operating procedure for safely managing three- and four-day prescriptions, including clinician-only issuing, scheduling, alerts, coding and regular review.

Verbatim wording from the response

“A draft SOP was prepared and discussed with the PCN Pharmacist on 18 July 2024. Amendments were made to remove any direct role for the PCN Pharmacists as they did not feel there was sufficient capacity within their team to respond in a timely manner to urgent requests. The SOP was reviewed and agreed at the Partners meeting the same day. The Lead GP for Mental”

Source location

Response from Park Surgery Heanor
Page 2 · response
Published 4 July 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

Review the three- and four-day prescribing SOP in July 2025.

Verbatim wording from the response

“3. The SOP will be reviewed in July 2025.”

Source location

Response from Park Surgery Heanor
Page 3 · response
Published 4 July 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

Consult local practices and the ICB prescribing team about managing frequent prescriptions and incorporate relevant learning into the practice SOP.

Verbatim wording from the response

“iii. Contact prescribing lead GPs in other local PCN Practices to enquire about experience with (and policies for) managing twice weekly prescriptions.”

Source location

Response from Park Surgery Heanor
Page 2 · response
Published 4 July 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

Seek information from the Community Mental Health Team about frequent-prescription processes and ongoing review requirements.

Verbatim wording from the response

“v. Contact the Community Mental Health Team (CMHT) to see if they have any policies regarding their processes for requesting 3 and 4-day prescriptions from GPs and also ensuring ongoing review of such patients, including whether there is a continuing need for twice-weekly prescriptions.”

Source location

Response from Park Surgery Heanor
Page 2 · response
Published 4 July 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

Add a READ code and home-screen safety alert to records of patients receiving three- or four-day prescriptions.

Verbatim wording from the response

“We agreed that administrative staff, who normally issue repeat prescriptions, should not be involved in issuing medications for patients on 3 and 4-day prescriptions. This is to reduce the risk of errors when issuing twice-dated prescriptions for medications where each item appears twice on the repeat medication list. We noted that we would need to include a reminder in the home screen for any patients on twice-weekly prescriptions, to alert staff that the patient is on twice-weekly prescriptions, and that we would create a READ code ‘Risk Reduction technique’ for audit purposes.”

Source location

Response from Park Surgery Heanor
Page 2 · response
Published 4 July 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.2

  1. 1

    Use a scheduled education and training session to reflect on the prescribing SOP, answer staff questions and provide updates.

    Stated by Park SurgeryStated plannedThe respondent said that this action was planned when they made their response on 4 July 2024.
  2. 2

    Undertake ongoing quality-improvement work on opioid prescribing, including reviewing high-dose patients, evaluating prescribing data, educating clinicians and supporting dose reduction where possible.

    Stated by Park SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 4 July 2024.

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

  1. 1

    The PCN Pharmacist team was not assigned a direct role because it lacked sufficient capacity to respond promptly to urgent prescribing requests.

    Stated by Park SurgeryUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 a scheduled education and training session to reflect on the prescribing SOP, answer staff questions and provide updates.

Verbatim wording from the response

“1. The next half-day education and training (QUEST) session at Park Surgery is on 18 September 2024, during which there will be an opportunity to reflect again on the SOP, answer any questions from the team and provide updates on any further information/advice from the CMHT.”

Source location

Response from Park Surgery Heanor
Page 3 · response
Published 4 July 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

Undertake ongoing quality-improvement work on opioid prescribing, including reviewing high-dose patients, evaluating prescribing data, educating clinicians and supporting dose reduction where possible.

Verbatim wording from the response

“2. We are also planning to undertake some quality improvement work in relation to opioid prescribing. We have already undertaken a review to identify any patients receiving high-dose opiates for non-cancer pain. There are 3 patients meeting this criterion and these patients will be reviewed with a view to reducing risk and opioid doses wherever possible. From August 2024, one of our GPs and a GP Registrar will undertake a wider review of opioid prescribing at Park Surgery. This is likely to include evaluation of data, education for the clinical team, de-prescribing, discussion around resources for patients etc. Although this work is likely to be ongoing, the time frame for the initial work is 12 months.”

Source location

Response from Park Surgery Heanor
Page 3 · response
Published 4 July 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 PCN Pharmacist team was not assigned a direct role because it lacked sufficient capacity to respond promptly to urgent prescribing requests.

Verbatim wording from the response

“A draft SOP was prepared and discussed with the PCN Pharmacist on 18 July 2024. Amendments were made to remove any direct role for the PCN Pharmacists as they did not feel there was sufficient capacity within their team to respond in a timely manner to urgent requests. The SOP was reviewed and agreed at the Partners meeting the same day. The Lead GP for Mental”

Source location

Response from Park Surgery Heanor
Page 2 · response
Published 4 July 2024

Open published response
Back to top

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