Poor medication withdrawal support
Absence of commissioned specialist services for GPs to help patients safely reduce or withdraw from prescribed dependency-forming medications.
50 items
6 sources
Source spread
Where this theme appears
Poor medication withdrawal support has been flagged across 6 independent accountability sources:
32 PFD reports
6 PPO recs
1 IMB rec
1 Scottish FAI
2 Article 2 learning points
8 PHSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
PFD Reports (32)
Paul Nash
Concerns: A GP surgery failed to prioritise urgent seizure medication, and epilepsy patients nationally face difficulties obtaining sufficient quantities, leading to poor seizure control and potential delays.
Response (Department of Health and Social Care): • Officials made enquiries with NHS England to address the coroner's concerns. • The government is committed to improving care for people with neurological conditions, including epilepsy, and ensuring they …
Responded
John Michael Bailey
Overdue
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 (Browning Street Surgery): The practice will endeavor to identify patients with additional complex needs for specific discussion at practice meetings to improve service to patients. They will also aim to maximise the health …
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 (Department of Health): The Department of Health acknowledges the coroner's concerns regarding repeat prescriptions of citalopram, referencing NICE guidelines. It states that NICE guidelines are not rules and do not restrict prescribing, including …
Response (Department of Health): The Department of Health acknowledges the coroner's concerns regarding citalopram prescriptions and psychotherapy waiting times but states these are the responsibility of the Welsh Government. It includes information about Citalopram's …
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.
Response (United Pharmacy): United Pharmacy pharmacists are working closely with patients' special workers, having regular meetings with Bromley Drugs and Alcohol services, and will encourage services to use pharmacies open at weekends for …
Overdue
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.
Response (Department of Health): The Department of Health acknowledges the concerns about GPs monitoring medication collection for mental health patients, but cites practical and ethical challenges to implementing such a system. NHS England advises …
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.
Response: The surgery has taken steps to ensure regular medication reviews are undertaken for patients on SSRIs and that patients are made aware of mental health support services, including raised awareness …
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.
Response (Doncaster and Bassetlaw Hospitals): The response indicates that the respiratory team is well versed with the current state of the evidence and are following appropriate current guidelines and are unable to produce useable local …
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.
Response (Manor Field Surgery): The practice identified patients prescribed tramadol and other medicines with the potential for self-harm and changed all electronic prescriptions to paper format for review. They have changed their policy for …
Responded
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.
Response (Fremington Medical Centre): The practice has sent personal letters to patients on repeat prescriptions for Benzodiazepines asking them to contact the practice for a medication review. The practice has made a commitment not …
Response (Royal College of General Practitioners): The Royal College of General Practitioners provides context on its role, describes its training and membership offerings, and references existing guidance on benzodiazepine prescribing. It supports a joint consensus statement …
Response (NHS England): NHS England will ask its National Clinical Director for mental health and Head of Mental Health and LD Medicines Strategy to write to medical directors and chief pharmacists in mental …
Response (Devon LMC): Devon LMC will remind practices about the review of patients receiving short-acting Benzodiazepines via its electronic newsletter and will make the information available on its website.
Responded
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
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
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
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.
Response (West Quay Centre): The practice has taken on a full-time Clinical Pharmacist to oversee repeat and acute prescribing, and patient monitoring. They achieved an NHS award for quality improvement in this area.
Response: The University Health Board conducted an internal review and will remind staff of the importance of full and diligent information taking. The matter of medication reviews has been raised with …
Responded
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
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
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.
Response (NHS Trafford Clinical Commissioning Group): NHS Trafford CCG has recently highlighted to practices that prescribing of analgesia is an area they could work collaboratively on to ensure that patients get the best outcomes from their …
Response (NHS Greater Manchester): NHS Greater Manchester will share learning from this and similar cases via governance forums, and CCGs will report on reducing over-prescribing of analgesia. They will also share advice and guidance …
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.
Response (NHS England): NHS England expresses condolences and explains its role as a facilitator for system partners working to deliver recommendations from a Public Health England review on prescribed medicines. It describes national …
Response (Hilltops Surgery): Hilltops Surgery reviewed the case, audited patients on high-dose opioids, ensured 3-monthly reviews for certain patient groups, discussed the case with the Integrated Care Board, and arranged a meeting to …
Responded
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.
Response (Burton Croft Surgery): Following the death, an alert was added to Leeds GP computer systems regarding propranolol risks for patients with depression, anxiety, or migraines. The ICB plans to raise awareness of the …
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
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.
Response (Wood Street Health Centre): Wood Street Health Centre audited patients prescribed Zopiclone/Zolpidem, is reviewing their medication, has moved to acute prescriptions only (max 2-week supply), instructs 'as required' use on prescriptions, informed local pharmacists, …
Response (North East London NHS Foundation Trust): North East London NHS Foundation Trust (NELFT) audited prescribing practice and revised its prescribing policy for hypnotics, is participating in a working group to improve medication monitoring across primary and …
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges the concerns raised and notes that NHS England is working to support prescribers in managing repeat prescribing; it also acknowledges actions being …
Responded
Steven Bowker
Concerns: The prolonged prescription and use of opiate medication pose significant dangers to patients.
Response (Department of Health and Social Care): The Department acknowledges the concerns regarding prolonged opiate prescriptions, explains the role of clinicians and the MHRA, and highlights existing guidance and monitoring processes, including updates to product information and …
Overdue
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.
Response (Kirby Road Surgery): The surgery has developed an action plan, clinical staff have undertaken training courses regarding opioid prescribing for chronic pain, opioid and gabapentinoid prescribing policies have been updated, and information has …
Responded
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.
Response (Ministry of Defence): The Ministry of Defence expresses condolences and states that Mr Day received significant medical input, including mental healthcare, occupational health, and primary medical care. While open to improvements, they don't …
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.
Response (Darent Valley Trust and Kent Medway NHS and Social Partnership): Darent Valley Trust and Kent Medway NHS and Social Partnership have taken several actions, including reminding staff to record handovers to enhanced care nurses, ensuring that risks to harm are …
Overdue
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.
Response (Flixton Road Medical Centre): Flixton Road Medical Centre details changes made including; reviewing and updating prescribing protocols, implementing mandatory risk-benefit discussions for new or escalated high-level opioid prescriptions, providing staff training in opioid safety …
Response (Greater Manchester Integrated Care): NHS GM outlines planned actions including increased use of the SMASH dashboard, pharmacy reviews of patients flagged by the SMASH opioid indicator, development of standards for primary care review of …
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.
Response (NHS England): NHS England acknowledges the concern and highlights its national role in providing guidance and support, specifically through Controlled Drugs Accountable Officers (CDAOs). The response notes that commissioning of services now …
Response (Mid and South Essex Integrated Care Board): An Opioid Reduction/Discontinuation Pathway is planned within the Community Musculoskeletal (MSK) Service, due for implementation in February 2026. The ICB Executive Committee has endorsed a proposal to scale up the …
Response (Department of Health and Social Care): The Minister acknowledges the concerns about the lack of specialist services for managing dependency-forming medicines and outlines national initiatives, including NHS England's work and the MHRA's review of codeine. It …
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.
Response (National Institute for Health and Care Excellence): NICE clarifies that the Clinical Knowledge Summaries (CKS) are not NICE guidance, and that NICE guidance and prescribing information for risperidone does not include a requirement for continued ECG monitoring. …
Response (NHS Derby and Derbyshire Integrated Care Board): The ICB will review the investigation from the practice, await the NICE response, update the JAPC guideline and medicines management webpage, and share lessons learned and guidance updates with primary …
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.
Response (Addison House Health Centre): Addison House Health Centre has reviewed and updated its prescribing policy, enhanced IT system alerts related to self-harm risk, and is restricting repeat medications for high-risk patients; these changes have …
Responded
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 (Your Health Partnership Regis Medical Centre): The practice will amend their risk assessment template to include a mental health medication review code and free text advice regarding stockpiled medications, patient safety with medication quantity, reducing medication …
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.
Response (Sheffield Health Partnership University NHS Foundation Trust): • The approach to monitoring service users following changes to antipsychotic medication has been strengthened and is being implemented, with full standardisation across all relevant services to be completed by …
Responded
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 (Northamptonshire Healthcare Foundation Trust): The trust has reminded prescribing clinicians of expectations for assessing and managing cumulative sedative burden, and has re-emphasized documentation standards. They have also introduced a new harm minimisation advice leaflet …
Responded
PPO Death in Custody Recommendations (6)
The Head of Healthcare
The Head of Healthcare should ensure there is a clinical process for monitoring prisoners who may be withdrawing from psychotropic medication associated with a risk of dependency and withdrawal.
The Head of Healthcare at HMP Wandsworth
The Head of Healthcare should incorporate closer healthcare observations for prisoners who are on a reduction regime and/or are being taken off Gabapentinoids, to monitor withdrawal symptoms and any adverse effects.
The Head of Healthcare at HMP Wandsworth
The Head of Healthcare should ensure that the prescribers have a face-to-face conversation with a prisoner if there is an intention to reduce or cease any high risk prescribed medication.
The Head of Healthcare (HMP Nottingham)
The Head of Healthcare should work in partnership with Nottingham Healthcare NHS Foundation Trust, the regional Health and Justice Leads and regional drug providers to satisfy themselves that the local policy on the offer and issue of naloxone on release …
The Head of Healthcare at HMP Thameside
The Head of Healthcare at HMP Thameside should ensure that prisoners are discharged or transferred with a sufficient supply of their prescribed medications.
The Head of Service Delivery for substance misuse
The Head of Service Delivery for substance misuse should satisfy themselves that the local policy on the offer and issue of naloxone on release captures prison leavers with previous opiate use and other relevant risk factors.
Scottish Fatal Accident Inquiries (1)
Article 2 Learning Points (2)
— LP 2
If a prisoner comes into prison on mirtazapine, he/she should have a full review, following confirmation of that prescription from the community GP. This should happen quickly. If an alternative to mirtazapine prescription is appropriate, the person should be reduced slowly from mirtazapine and the new drug introduced gradually, as …
HMP Altcourse and HMPPS
Accepted
— LP 1
There needs to be much speedier medicines reconciliation, post reception. In prisoners, like Mr Everest, who are prescribed drugs like antidepressants, this needs to be within 24 hours to avoid withdrawal symptoms. There needs to be a robust administration process whereby a summary is acquired from the GP in the …
HMP Altcourse and HMPPS
Partially Accepted
PHSO Casework Decisions (8)
P-001226 — A medical practice in the Hartlepool area
Mr R complains a medical practice in the Hartlepool area reduced and stopped his fentanyl medication too rapidly and without discussion.
NHS in England
Upheld
Dec 2021
P-002804 — Torbay and South Devon NHS Foundation Trust
Mr E and Mrs O complain about the how the Trust managed their father’s withdrawal from alcohol during his admission.
NHS in England
Upheld
Jul 2024
P-003281 — The Dudley Group NHS Foundation Trust
Miss A complains about various decisions clinicians made during her mother’s admission in 2021.Findings leading to recommendationsWhat we are asking the Trust to do for Miss A:Complaint issueWhat we have seen so farWhat we are likely to ask the organisation to doWhat we would need to see and whenWithdrawal of …
NHS in England
Partly Upheld
Jan 2025
P-002303 — South West Yorkshire Partnership NHS Foundation Trust
Miss H complains the Trust changed her olanzapine medication (an antipsychotic medicine used to treat schizophrenia) and would not let her go back on it.
NHS in England
Upheld
Nov 2023
P-002748 — Surrey and Sussex Healthcare NHS Trust
Mrs L complains the Trust incorrectly stopped medication to treat her mental health condition which led to a long hospital stay and affected her mobility and mental health.
NHS in England
Jul 2024
P-002761 — A practice in the Hackney area
Miss P complains about how the Practice cared for her mother. She says it stopped medication rather than reduce it slowly and it failed to review her mother after a month. She also says it lied in its complaint response.
NHS in England
Jul 2024
P-003121 — Cheshire and Wirral Partnership NHS Foundation Trust
Mr R complains the Trust decided to stop his clozapine medication after a standard monthly blood test on 18 July 2023, without putting in place an alternative treatment plan.
NHS in England
Nov 2024
P-004419 — Greater Manchester Mental Health NHS Foundation Trust
Mrs A complains about the discharge process and the lack of medication reviews prior to discharge.
NHS in England
Nov 2025