Riverview Surgery
Action Taken
Riverview Surgery has implemented a new Standard Operating Protocol (SOP) for prescribing medication to women of childbearing age, which includes stopping contraindicated medication and advising patients if they become pregnant. The frequency of reviews for female patients on ARB medication has been increased to three-monthly. (AI summary)
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Dear Mr Place
Avery Jake Hall: Prevention of Future Deaths Report
I am writing on behalf of the Riverview Surgery in response to your Prevention of Future Deaths Report (PFDR) dated 2 February 2026 in order to provide you with information regarding the further steps we are taking in addition to those set out in the SEA to ensure that there is no recurrence of these devastating events.
For completeness, I attach the SEA detailing the steps taken previously. Following receipt of your PFDR, I have considered carefully your concerns and conclusion and revisited the SEA in order to further develop the systems currently in place, to address your concerns. These additional changes are as follows:
1. An SOP has been implemented in relation to prescribing medication to women of child bearing age (15-55 years old). I attach the SOP. A clinical practice meeting has been arranged for 26 February 2026 at which the SOP will be discussed and laminated copies distributed.
2. The SOP goes further than the previous SEA in the following respects:
a. It relates to any new medication at the point of initiation.
b. If there is a concern as to a medication’s safety in pregnancy, the medication is to be stopped and removed from the repeat and acute list of medications and the patient advised of safe alternative medication.
3. As set out in the SEA, a review of all female patients of child bearing age who are prescribed ARB medication was to be undertaken every 6 months and an alert added to their prescription to stop taking this medication if they become pregnant and to speak to their GP. The frequency of this review has now been increased to 3-monthly in light of the risks of this medication in later pregnancy. In addition, as most prescriptions are now electronic rather than paper copies, the alert will be added to the prescribing instructions section so that it is clearly shown on the label printed for the patient’s medication by the pharmacy when they collect their medication.
I wish to make clear that had I known of the BNF warning for candesartan in 2024, I would have given definitive advice that it must be stopped and I would have removed it from the repeat prescription list. The SOP will ensure that patients receive an early alert and counselling in relation to any concerns about their current medications should they become pregnant. Once the patient informs the practice of their pregnancy, an urgent review will take place with a doctor to address their current medication risks, stop medications which are contraindicated or for which there is concern about their safety in pregnancy and advise upon safe alternatives. Had the SOP been in existence in April 2024, it would have led me to stop the 3 medications which the BNF advised avoiding or were contraindicated in pregnancy, namely candesartan, melatonin and lansoprazole, and to remove them from the acute and repeat prescription lists.
I have also considered further whether it is possible to identify or flag a pregnant patient when they request repeat medication. This would be an important safeguard for doctors reviewing the two hundred or so repeat medication requests received on a daily basis. Due to their volume and the other priorities for clinicians’ time, it is not practical for the doctor to review each patient’s records when authorising every request. We do not have the technical IT skills at the practice to make changes to the computerised records system and I have therefore contacted our system provider EMIS to ask for their advice and input on whether it is possible, and if so how, to introduce a flag which would identify the pregnancy coding on the patient’s record and link it to the repeat prescriptions for the patient (and ideally include the BNF advice for that medication as well). I hope that this is a proportionate and practical way to address the
issue you have raised, which will further strengthen the safeguards in place with the 3 monthly review of all female patients of child bearing age prescribed ARB medication.
I wish to make clear how seriously I and the practice take the issues you have raised and hope you are reassured by the steps already undertaken and the further steps which are being undertaken following your PFDR.
Avery Jake Hall: Prevention of Future Deaths Report
I am writing on behalf of the Riverview Surgery in response to your Prevention of Future Deaths Report (PFDR) dated 2 February 2026 in order to provide you with information regarding the further steps we are taking in addition to those set out in the SEA to ensure that there is no recurrence of these devastating events.
For completeness, I attach the SEA detailing the steps taken previously. Following receipt of your PFDR, I have considered carefully your concerns and conclusion and revisited the SEA in order to further develop the systems currently in place, to address your concerns. These additional changes are as follows:
1. An SOP has been implemented in relation to prescribing medication to women of child bearing age (15-55 years old). I attach the SOP. A clinical practice meeting has been arranged for 26 February 2026 at which the SOP will be discussed and laminated copies distributed.
2. The SOP goes further than the previous SEA in the following respects:
a. It relates to any new medication at the point of initiation.
b. If there is a concern as to a medication’s safety in pregnancy, the medication is to be stopped and removed from the repeat and acute list of medications and the patient advised of safe alternative medication.
3. As set out in the SEA, a review of all female patients of child bearing age who are prescribed ARB medication was to be undertaken every 6 months and an alert added to their prescription to stop taking this medication if they become pregnant and to speak to their GP. The frequency of this review has now been increased to 3-monthly in light of the risks of this medication in later pregnancy. In addition, as most prescriptions are now electronic rather than paper copies, the alert will be added to the prescribing instructions section so that it is clearly shown on the label printed for the patient’s medication by the pharmacy when they collect their medication.
I wish to make clear that had I known of the BNF warning for candesartan in 2024, I would have given definitive advice that it must be stopped and I would have removed it from the repeat prescription list. The SOP will ensure that patients receive an early alert and counselling in relation to any concerns about their current medications should they become pregnant. Once the patient informs the practice of their pregnancy, an urgent review will take place with a doctor to address their current medication risks, stop medications which are contraindicated or for which there is concern about their safety in pregnancy and advise upon safe alternatives. Had the SOP been in existence in April 2024, it would have led me to stop the 3 medications which the BNF advised avoiding or were contraindicated in pregnancy, namely candesartan, melatonin and lansoprazole, and to remove them from the acute and repeat prescription lists.
I have also considered further whether it is possible to identify or flag a pregnant patient when they request repeat medication. This would be an important safeguard for doctors reviewing the two hundred or so repeat medication requests received on a daily basis. Due to their volume and the other priorities for clinicians’ time, it is not practical for the doctor to review each patient’s records when authorising every request. We do not have the technical IT skills at the practice to make changes to the computerised records system and I have therefore contacted our system provider EMIS to ask for their advice and input on whether it is possible, and if so how, to introduce a flag which would identify the pregnancy coding on the patient’s record and link it to the repeat prescriptions for the patient (and ideally include the BNF advice for that medication as well). I hope that this is a proportionate and practical way to address the
issue you have raised, which will further strengthen the safeguards in place with the 3 monthly review of all female patients of child bearing age prescribed ARB medication.
I wish to make clear how seriously I and the practice take the issues you have raised and hope you are reassured by the steps already undertaken and the further steps which are being undertaken following your PFDR.