Poor medication withdrawal support
31 items
1 source
Absence of commissioned specialist services for GPs to help patients safely reduce or withdraw from prescribed dependency-forming medications.
Cross-Source Insight
Poor medication withdrawal support has been flagged across 1 independent accountability source:
31 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (31)
Fallon Adams
Concerns: There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative medications with illicit drugs, which can cause fatal over-sedation.
Response: The Trust has reminded prescribing clinicians of expectations regarding assessment and management of sedative burden, re-emphasised documentation standards for clinical observations, and introduced a new harm minimisation advice leaflet for …
Responded
Jason White
Concerns: Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of relapse and serious deterioration in the patient's mental health.
Overdue
Danielle Jones
Concerns: The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the patient self-reporting multiple overdoses and external services raising concerns.
Response: The practice plans to amend its Prescribing Policy by January 2026 to include clear guidance on medication quantities and reducing amounts if there is a self-harm risk. It will also …
Responded
Mark Smith
Concerns: The GP practice lacked a system or policy to ensure appropriate medication reviews for vulnerable patients with addiction or self-harm history, risking stockpiling and misuse of prescribed drugs.
Responded
Aaron Atkinson
Concerns: There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for at least 12 months after initiating antipsychotic medication.
Responded
Michael Barry
Concerns: There is a critical lack of commissioned specialist services for GPs to safely manage patients reducing or withdrawing from prescribed dependency-forming medications, risking avoidable deaths.
Responded
Louise Rosendale
Concerns: The practice failed to conduct sufficient long-term review and oversight of a patient's long-term opiate prescription, despite the associated risks, indicating a lack of detailed planning for such patients.
Responded
Sarah Keen
Concerns: Critical patient information, including self-harm risk and medication details, was not communicated to carers. There was also a failure to standardize the understanding of medical abbreviations among staff, impacting patient safety.
Overdue
James Day
Concerns: Inadequate and difficult-to-access mental health support for service personnel with PTSD, both during and after service, forces individuals to self-medicate, leading to poor outcomes.
Responded
Joy Ebanks
Concerns: Prolonged prescribing of dependency-forming drugs (Oxycodone, Pregabalin) without reduction plans, despite internal guidance on the hazards of long-term use, contributed to toxicity.
Responded
Steven Bowker
Concerns: The prolonged prescription and use of opiate medication pose significant dangers to patients.
Overdue
Amanda Kramer
Concerns: A patient was prescribed Zoplicone for 18 years without review, despite the drug's short-term license and her high-risk overdose behaviour, raising concerns about medication management.
Responded
Robert Stevenson
Concerns: Prescribing doctors may be unaware of a rare potential link between Ciprofloxacin/Quinolone antibiotics and suicidal behaviour, especially in depressed patients. Guidelines should be reviewed to increase awareness and mitigate this risk.
Overdue
Aoife McAdam
Concerns: A patient prescribed a cardiotoxic medication for anxiety was not advised to safely dispose of it after switching, leaving her with a significant, unneeded quantity that led to an overdose.
Responded
Jacqueline Campbell
Concerns: Dangerous polypharmacy involving escalating doses of synergistic pain medications led to central respiratory depression, exacerbated by difficulties for GPs in managing drug dependency and a lack of proactive medication review protocols.
Overdue
Michelle Jeffries
Concerns: There is an absence of clear local guidance for GPs on safely prescribing multiple high-dose analgesics in the community and when a mandatory referral to a pain specialist is required.
Responded
KennethDaly
Concerns: Unclear advice from consultants regarding co-prescribing multiple opioids and a lack of tailored written guidance for patients on the risks of combined opioid use were identified.
Overdue
Kathryn Barrow
Concerns: GPs prescribed Diazepam without verifying consultant advice or checking for illicit access, and the practice had not reviewed its prescribing approach for this medication.
Overdue
Ruth Edwards
Concerns: Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate history-taking led to underestimated risk, and insufficient GP medication reviews created an overdose risk.
Responded
Scott Carton
Concerns: Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without specialist input, compromises rehabilitation and increases re-offending risk.
Overdue
Lakhminder Kaur
Concerns: Concerns arose regarding unmanaged long-term zopiclone addiction and the immediate cessation of the drug, which was done to prevent serious self-harm.
Overdue
Marcus Hamilton
Concerns: The mental health service's rigid 28-day prescription policy for maintenance medication left a patient vulnerable during extended travel, providing unreliable advice about obtaining drugs illicitly abroad.
Overdue
Carly Gordon
Concerns: The long-term use of shorter-acting benzodiazepines, contrary to guidelines, and a failure to review patients on extended prescriptions risked dependence and adverse outcomes.
Responded
Craig Hamilton
Concerns: A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss alternative pain management, poses significant risks.
Responded
Thomas Pearson
Concerns: A patient was prescribed fluticasone, increasing pneumonia risk without benefit due to a non-raised eosinophil count. The coroner recommends reviewing inhaled steroid use in similar patient populations.
Responded
Tania Hristova
Concerns: The patient received antidepressant medication for over five years without adequate review and was not offered additional psychological therapies such as counselling or CBT.
Responded
John Ioannou
Concerns: There is a lack of clear guidance for General Practitioners when patients fail to collect essential mental health medication, potentially compromising treatment continuity and patient well-being.
Responded
Deanne Smith
Concerns: The practice of dispensing large quantities of methadone to drug-dependent individuals over public holidays increases the risk of future deaths and needs policy review.
Overdue
Lee Bonsall
Concerns: Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it an unviable treatment alternative.
Response: The Department of Health disputes that national guidelines restrict the repeat prescribing of citalopram, stating they are not rules and prescribing remains a clinical responsibility. They will, however, forward the …
Response: The Department of Health notes that the tragic events occurred in Wales, placing responsibility with the Welsh Government, and recommends the report be sent to them.
Responded
Pauline Meredith
Concerns: Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's perceived reluctance to address family concerns. Delayed involvement of mental health services was also noted.
Response: The surgery is undertaking an audit of all patients on opioid medication, developing a new protocol for prescribing opioids for chronic pain, and will train staff on this protocol. They …
Overdue
John Michael Bailey
Overdue