Themes | Healthcare & Patient Safety | The Accountability Index

Poor medication withdrawal support

Absence of commissioned specialist services for GPs to help patients safely reduce or withdraw from prescribed dependency-forming medications.

Source spread

Where this theme appears

This theme appears across 10 independent accountability sources, so the source mix matters as much as the headline total.

32 PFD reports 6 PPO recs 2 IOPC recs 1 IMB rec 2 Scottish FAIs 2 Article 2 learning points 4 DHR recs 8 PHSO decisions

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.

10 sources
Prevention of Future Deaths reports(32)
Paul Nash
19 Mar 2026 · Bedfordshire and Luton
Concerns: The GP surgery did not prioritise an urgent prescription for seizure medication after information about the deceased running out was not fully conveyed. Concerns were also raised about nationwide difficulties for epilepsy patients in obtaining sufficient medication quantities and pharmacy processing delays.
Response (Department of Health and Social Care): • NHS England issued a patient safety incident notification to community pharmacy contractors regarding the importance of supplying time-critical medicines. • NHS England reviewed the Pharmacy First service specification, identifying … (AI summary)
Response (Sundon Medical Centre): • The practice created a Critical Medication List and updated prescribing instructions for epilepsy medications to clearly state the indication and total dose. • A formal process for identifying and … (AI summary)
Responded
John Michael Bailey
09 Sep 2013 · South Yorkshire (West)
Concerns: The coroner noted an absence of clear protocol guidance and a robust system for primary care physicians managing Amiodarone, along with inconsistent Shared Care Protocols across different Trusts, which could pose risks to patients and transferring staff.
Overdue
Pauline Meredith
10 Jan 2014 · Staffordshire South
Concerns: The coroner identified concerns regarding the lack of a formal medication review process for a patient on long-term, high-dose medication, especially the addition of morphine with alcohol dependence. The report also noted a perceived reluctance by the GP to address family concerns and insufficient engagement with community mental health services.
Response (Browning Street Surgery): • The practice has formally instigated a programme of regular meetings to review all deaths in patients under 50 and will develop criteria to identify complex patients for discussion at … (AI summary)
Overdue
Lee Bonsall
31 Jan 2014 · Carmarthenshire & Pembrokeshire
Concerns: The coroner noted that citalopram was given on repeat prescription contrary to guidelines, and questioned if GPs were aware of them. Concerns were also raised about ten-month waiting times for psychotherapy, making it an unviable alternative to medication.
Response (Department of Health): • NICE stated it would review its guidelines on depression (CG90). • The Secretary of State confirmed it would forward the coroner's prescribing concerns to NICE for consideration in their … (AI summary)
Response (Department of Health): • The Department of Health outlined existing guidance and responsibilities for repeat prescribing of medication in England. • The Department of Health and NHS England are committed to developing and … (AI summary)
Responded
Deanne Smith
31 Mar 2014 · London (South)
Concerns: The coroner raised concerns about the policy of dispensing several days' supply of methadone to drug-dependent individuals during public holidays, noting the risk of future deaths when usual provision methods are suspended.
Response (United Pharmacy): • United Pharmacy pharmacists are working with patient special workers to exchange information on clients using Bromley Drugs and Alcohol services. • United Pharmacy holds regular meetings with Bromley Drugs … (AI summary)
Overdue
John Ioannou
06 Jan 2015 · London (North)
Concerns: The coroner identified a lack of guidance for GPs on managing patients who do not collect medication required for their mental health conditions.
Response (Department of Health): • NHS England sought advice from its Primary Care Patient Safety Expert Group and Mental Health Patient Safety Expert Group on feasible actions regarding monitoring medication collection. • NHS England … (AI summary)
Responded
Tania Hristova
28 Sep 2015 · Wiltshire and Swindon
Concerns: The coroner noted the patient was prescribed antidepressant medication for over five years without adequate review and was not offered additional therapies such as counselling or CBT.
Response: • The practice undertook an audit to identify patients due for SSRI antidepressant reviews and contacted them to arrange appointments. • The repeat prescribing system was upgraded to electronic prescribing, … (AI summary)
Responded
Thomas Pearson
04 Jul 2016 · South Yorkshire (East)
Concerns: The coroner noted concerns regarding the continued use of fluticasone in patients like Mr Pearson, where it presented an increased risk of pneumonia without corresponding benefits, and suggested a review of its use.
Response (Doncaster and Bassetlaw Hospitals): • The respiratory team held discussions regarding the use of inhaled corticosteroids in chronic obstructive pulmonary disease. • The team works collaboratively and regularly discusses a variety of clinical topics. … (AI summary)
Responded
Craig Hamilton
13 Jun 2017 · South Yorkshire (East)
Concerns: The coroner identified a lack of clear procedures for managing and monitoring patients who seek to obtain more medication than prescribed, and for exploring alternative pain management during reviews. Concerns were also raised about systems for discussing dosage implications with patients and recording such discussions.
Response (Manor Field Surgery): • The surgery identified patients prescribed tramadol and other high-risk medications, changing electronic prescriptions to paper for doctor review. • It completed a thorough review of medication ordering and review … (AI summary)
Responded
Carly Gordon
04 Aug 2017 · Exeter & Greater Devon
Concerns: Concerns were raised regarding the long-term prescription of shorter-acting benzodiazepines instead of longer-acting ones, contrary to British Association of Psychopharmacology Guidelines. The coroner also noted the need for regular medical review for patients on extended courses of this medication to reassess suitability.
Response (Fremington Medical Centre): • The General Practitioner stated they would change future prescribing practice regarding the use of shorter-acting benzodiazepines. • The practice implemented a structured systemic approach for reviewing patients on benzodiazepines. … (AI summary)
Response (Royal College of General Practitioners): • The Royal College of General Practitioners (RCGP) provides guidance on benzodiazepine use, including a 2013 consensus statement. • The RCGP curriculum includes safe prescribing and medicines management approaches, which … (AI summary)
Response (NHS England): • NHS England stated it would ask its National Clinical Director for mental health and Head of Mental Health and LD Medicines Strategy to write to medical directors and chief … (AI summary)
Response (Devon LMC): • Devon LMC stated it would remind practices about reviewing patients receiving short-acting benzodiazepines via its electronic newsletter. • Devon LMC stated it would make the information available on its … (AI summary)
Responded
Marcus Hamilton
05 Jan 2018 · Manchester (South)
Concerns: The coroner noted GMMH's policy limited prescription supply to 28 days, leading to a patient running out of essential medication on a longer trip and potentially having to source it from an illicit market abroad.
Overdue
Lakhminder Kaur
24 Jan 2018 · Black Country
Concerns: The coroner noted Mrs Kaur's long-term addiction to zopiclone and identified concerns with the decision to abruptly discontinue the medication to prevent self-harm.
Overdue
Scott Carton
07 Sep 2018 · West Yorkshire (East)
Concerns: The report identifies a lack of appropriate psychological support for Mr Carton's emotionally unstable personality disorder and drug dependence in his hostel and prison placements. It also notes insufficient psychological resources for prisoners with similar conditions upon release, impeding successful reintegration.
Overdue
Ruth Edwards
18 Dec 2018 · SouthWales Central
Concerns: The coroner noted a surprising discharge from hospital after an overdose without a psychiatric liaison assessment, poor history-taking at UHW, and insufficient GP medication reviews contributing to an overdose risk.
Response (West Quay Centre): • The practice appointed a full-time Clinical Pharmacist within the last 12 months to oversee and improve governance regarding repeat and acute prescribing and patient monitoring. • The practice achieved … (AI summary)
Response: • The Health Board stated that all staff will be reminded of the importance of full and diligent information taking. • The issue of frequent medication reviews will be raised … (AI summary)
Responded
Kathryn Barrow
19 Sep 2019 · Manchester (South)
Concerns: Mrs. Barrow received Diazepam prescriptions without confirmation from mental health services or adequate GP checks regarding illicit access to the medicine. The practice also had not recently reviewed its approach to prescribing Diazepam.
Overdue
KennethDaly
23 Oct 2019 · London Inner (North)
Concerns: The consultant's advice to the GP regarding the continuation of certain pain medications was unclear, and the GP did not seek further guidance. The patient did not receive tailored written advice on his pain relief regimen or the risks of combining multiple opioid medications.
Response (Rochdale Boroughwide Housing Limited): • Rochdale Boroughwide Housing stated it would not consider a wholesale installation programme for carbon monoxide detectors until the outcome of a government review is known. • The organisation will … (AI summary)
Overdue
Michelle Jeffries
22 Nov 2021 · Manchester South
Concerns: The coroner noted an absence of local guidance for GPs regarding the safe oversight of multiple high-dose analgesic prescriptions in the community and when referral to a pain specialist is required.
Response (NHS Trafford Clinical Commissioning Group): • The CCG Medicines Optimisation team highlighted analgesia prescribing as an area for collaborative work with practices. • The CCG's Repeat Prescribing guidance is under review and is scheduled for … (AI summary)
Response (NHS Greater Manchester): • The Repeat Prescribing guidance is currently under review and will be completed by March 31, 2022. • Learning from this case will be presented to the Greater Manchester Quality … (AI summary)
Responded
Jacqueline Campbell
22 Feb 2023 · Milton Keynes
Concerns: The coroner noted the severe safety risk of polypharmacy involving gabapentinoids and opiates for patients with iatrogenic drug dependency. There were no active plans by the GP practice to identify and rationalize medication for existing patients at risk.
Response (NHS England): • NHS England has launched a Medicines Safety Improvement Programme to reduce harm from opioid medicines, aiming for a 50% reduction in high-dose prescribing for non-cancer pain by March 2024. … (AI summary)
Response (Hilltops Surgery): • The surgery reviewed the case in a Multi-Disciplinary Meeting and conducted audits of patients on high-dose opioids, repeating the audit and arranging patient reviews. • It identified and reviewed … (AI summary)
Responded
Aoife McAdam
27 Mar 2023 · West Yorkshire (Eastern)
Concerns: The coroner noted that the patient was not advised to safely dispose of unused propranolol tablets when switching to a different medication. This left her in possession of a significant quantity of a potentially cardiotoxic drug she no longer needed.
Response (Burton Croft Surgery): • The Practice updated its Repeat Prescribing Policy to ensure clinicians advise patients to return unused medication to pharmacies for safe disposal. • An Optimise Rx alert was implemented across … (AI summary)
Responded
Robert Stevenson
07 Jun 2023 · West Yorkshire (Western)
Concerns: The coroner raises concerns that current guidelines for Ciprofloxacin and Quinolone antibiotics do not sufficiently emphasise a potential rare link to suicide behaviour, noting that prescribing doctors may lack full awareness of this side effect.
Overdue
Amanda Kramer
11 Sep 2023 · East London
Concerns: The coroner noted that Mrs Kramer was prescribed Zopiclone, a short-term medication, for 18 years without clear evidence of review by her GP or mental health trust, even following instances of high-risk behaviour.
Response (Wood Street Health Centre): • The Practice identified all patients prescribed Zopiclone or Zolpidem and initiated a review process to create plans for medication reduction or cessation. • Prescriptions for Zopiclone and Zolpidem were … (AI summary)
Response (North East London NHS Foundation Trust): • The Trust implemented a process for reviewing Zopiclone prescriptions for new and existing patients, supported by senior clinical oversight and a six-monthly audit. • Staff received training on the … (AI summary)
Response (Department of Health and Social Care): • The Royal Pharmaceutical Society was commissioned to provide a repeat prescribing toolkit. • An action plan was published in March 2023 to help local health care providers reduce inappropriate … (AI summary)
Responded
Steven Bowker
02 Dec 2023 · Manchester South
Concerns: The coroner raises concerns about the potential dangers to patients associated with the prolonged prescription and use of opiate medication.
Response (Department of Health and Social Care): • NHS England published a framework for action in March 2023 for Integrated Care Boards (ICBs) to reduce inappropriate prescribing of dependence-forming medicines. • The NHS Business Services Authority provides … (AI summary)
Overdue
Joy Ebanks
02 Jan 2024 · Bedfordshire and Luton
Concerns: The coroner noted prolonged prescribing of two dependency-forming drugs without a clear plan for dose reduction, despite the practice's own guidance highlighting the hazards of long-term opioid and gabapentinoid use for chronic pain.
Response (Kirby Road Surgery): • The surgery conducted a significant event analysis and discussed the case at organisational meetings. • A specialist prescribing pharmacist was recruited, and patients on opioid and gabapentinoid medications were … (AI summary)
Responded
James Day
07 Feb 2024 · Manchester South
Concerns: The coroner identified inadequate and difficult-to-access mental health support for service personnel with severe PTSD, both during their service and following discharge, which did not fully recognise the impact of traumatic events.
Response (Ministry of Defence): • The Head of the Defence Inquests Unit was asked to provide details of the support Mr Day received. (AI summary)
Responded
Sarah Keen
04 Mar 2024 · Mid Kent and Medway
Concerns: The coroner noted insufficient information sharing with carers regarding the patient's self-harm risk and medication management, inadequate communication of discharge medication recommendations by the psychiatrist, and a lack of universal understanding of the "DSH" abbreviation among medical staff.
Response (Darent Valley Trust and Kent Medway NHS and Social Partnership): • Staff will record handovers to enhanced care nurses, detailing patient risks. • Staff will seek to understand patients' remaining medication at home and communicate with supporting staff regarding discharge … (AI summary)
Overdue
Louise Rosendale
30 Apr 2025 · Manchester South
Concerns: The coroner noted insufficient review and oversight of long-term opiate prescriptions for patients within the practice. There was also a significant delay between identifying a patient on such a prescription and the next planned action.
Response (Flixton Road Medical Centre): • The practice completed a comprehensive review of opioid prescribing, which led to a revised policy, mandatory prescriber training, and an audit of high-risk prescribing. • A robust process for … (AI summary)
Response (Greater Manchester Integrated Care): • The locality plans to work with GP practices to increase use of the Safety Medication (SMASH) dashboard, including a new opioid indicator. • A pharmacy technician and pharmacist will … (AI summary)
Responded
Michael Barry
12 Jun 2025 · Essex
Concerns: The coroner identified a continuing lack of a commissioned specialist service for GPs to refer patients to for safe reduction and withdrawal from prescribed dependency-forming medications, which presents a risk of future deaths.
Response (NHS England): • NHS England published a framework in March 2023 to guide Integrated Care Boards (ICBs) and primary care in optimising personalised care for adults prescribed dependency-forming medications. • NHS England … (AI summary)
Response (Mid and South Essex Integrated Care Board): • The Mid and South Essex Integrated Care Board (ICB) has implemented prevention and education strategies, including a public communications campaign and e-learning for clinicians. • Comprehensive guidelines for managing … (AI summary)
Response (Department of Health and Social Care): • The Department noted that the specific local enhanced service referenced by the coroner was not nationally commissioned, and the local Trust is not commissioned to provide a stand-alone service … (AI summary)
Responded
Aaron Atkinson
30 Jun 2025 · Derby and Derbyshire
Concerns: Concerns were raised about the lack of annual ECGs during GP reviews for individuals prescribed long-term anti-psychotic medication. This appears to stem from a lack of clarity and consistency in national and local guidance regarding the recognised cardiac risks.
Response (National Institute for Health and Care Excellence): • The National Institute for Health and Care Excellence (NICE) shared the Prevention of Future Deaths report with Agilio Software. • Agilio Software will add wording to the Clinical Knowledge … (AI summary)
Response (NHS Derby and Derbyshire Integrated Care Board): • The Integrated Care Board (ICB) stated it would amend its local Joint Area Prescribing Committee (JAPC) guidance to advise annual electrocardiogram (ECG) monitoring for all patients on antipsychotics after … (AI summary)
Responded
Mark Smith
24 Sep 2025 · Essex
Concerns: The GP practice lacks a system or policy for appropriate medication reviews, frequency, and volume of repeat prescriptions for vulnerable patients with a history of addiction or self-harm, raising the risk of stockpiling and potential misuse.
Response (Addison House Health Centre): • The practice conducted an audit of high-risk patients, leading to medication/risk reviews and restriction of repeat medications to seven-day periods for identified individuals. • The Polypharmacy and High-Risk Prescribing … (AI summary)
Responded
Danielle Jones
27 Oct 2025 · The Black Country
Concerns: The coroner noted insufficient medication review by the GP for a patient who repeatedly disclosed overdose attempts with prescribed drugs, leading to continued large-amount prescriptions without further clinical rationale. Concerns were also raised about whether communication from a drug and alcohol service reached the treating GP.
Response (Your Health Partnership Regis Medical Centre): • The organisation discussed the issue of medication review with the individual clinician involved and communicated the need for review to clinicians via a newsletter and team meetings. • The … (AI summary)
Responded
Jason White
19 Dec 2025 · South Yorkshire East
Concerns: The coroner raised concerns that antipsychotic medication was abruptly stopped and the daily monitoring plan was not followed, creating a risk of relapse and mental health deterioration.
Response (Sheffield Health Partnership University NHS Foundation Trust): • The Trust has strengthened its approach to monitoring service users following changes to antipsychotic medication. • Requests for enhanced monitoring are now formally logged and reviewed at daily multidisciplinary … (AI summary)
Responded
Fallon Adams
29 Dec 2025 · Cambridgeshire and Peterborough
Concerns: The coroner noted concerns that Ms Adams, who was prescribed sedative medication, was not given a specific warning about the risks of over-sedation when combining prescribed and non-prescribed medication. It was also unclear if such specific warnings were being implemented.
Response (Northamptonshire Healthcare Foundation Trust): • Prescribing clinicians have been reminded of expectations concerning patient discussions and record-keeping for medication interactions. • Prescribing clinicians have been reminded of expectations for assessing and managing cumulative sedative … (AI summary)
Responded
NCEPOD recommendations(1)
PPO death in custody recommendations(6)
IOPC learning recommendations(2)
IMB individual recommendations(1)
Health investigations(10)
Independent investigation: Colin Greenway, Thamesmead (2013) — Rec 4
Clinicians should always conduct medication reductions in a systematic manner and guidelines should be developed to support all such decisions. The following should always be considered prior to medication reduction: the role medication has played in the maintenance of recovery; the service user’s mental health response to previous periods of …
london
Independent investigation: William Moss, Newquay (2007) — Rec 12
The Avon and Wiltshire NHS Partnership Trust should review and audit its prescribing practices, especially with respect to the prescribing of prophylactic and maintenance doses of medication and the regimen for withdrawing medication, to ensure that these comply with Best Practice Guidance
south_west
Independent investigation: Nihaal Kapede, Staincliffe (2000) — Rec 11
An appropriate structure should be agreed in terms of follow up needs of individuals, especially during a period of cessation of medication in vulnerable cases.
north_east_yorkshire
An independent review of the care and treatment received by … — Rec Supplementary recomm
In addition there is a supplementary recommendation for NHS England regional team and the local NHS Integrated Care Board. These organisations may wish to consider a review of the period of time between when Charles last took his antipsychotic medication in 2017 to when he was sectioned in under the …
north_east_yorkshire
Independent investigation into the care and treatment of Patient R: … — Rec 5
The Trust should ensure that any requests for a specific medication are fully explored with the service user and the possibility of dependency is considered and discussed.
5 Boroughs Partnership NHS Foundation Trust north_west Accepted
An independent investigation into the care and treatment of a … — Rec 2
The Trust must revise their clozapine administration guidance to include the education of patients and families, and the management of risk if clozapine is stopped suddenly.
east_of_england
Independent investigation: Jennifer Mills-Westley, Tenerife (2011) — Rec 12
The health board to ensure that patients on medication and who then take their own leave against medical advice, are appropriately supported in their medication needs at the time of discharge.
wales
Independent investigation: Colin Anderson, Newcastle (2006) — Rec 4
Where GPs are managing patients with mental health problems without involvement of secondary services, it is essential that long running prescriptions of medication – especially benzodiazepines – are regularly reviewed in face to face appointments. Where new medication has been introduced, or doses significantly altered, reviews should be arranged to …
north_east_yorkshire
An independent review of the care and treatment received by … — Rec R8
The trust should review its approach to medicines management/optimisation, particularly for those patients who are non-compliant with their atypical antipsychotic medication. This should include working towards a system of reinitiating atypical antipsychotics (such as clozapine) in the community, with 24-7 access to rapid screening tests and results. The trust should …
north_east_yorkshire
Independent investigation into the care and treatment of Mr F: … — Rec 7
Both primary and secondary health care services should be considering the possible psychological effects and the potential for misuse of prescribed medication in patients with chronic or ongoing physical health issues. This issue should be considered within the patient’s mental health risk and care planning.
Tees, Esk and Wear Valleys NHS Foundation Trust north_east_yorkshire
Scottish Fatal Accident Inquiries(2)
Article 2 learning points(2)
PHSO casework decisions(8)
P-001226 — A medical practice in the Hartlepool area
Mr R complained a medical practice rapidly reduced and stopped his fentanyl medication without discussion, causing pain and withdrawal trauma, and handled his complaint poorly.
NHS in England Upheld Dec 2021
P-002804 — Torbay and South Devon NHS Foundation Trust
Mr E and Mrs O complained their father was not adequately monitored or reviewed, and was inappropriately given sedative medication, potentially leading to his unexpected death.
NHS in England Upheld Jul 2024
P-003281 — The Dudley Group NHS Foundation Trust
Miss A complained about medication mismanagement for her mother, including stopping essential drugs, incorrect dosages, and feeding despite aspiration risk, which she believed contributed to her death.
NHS in England Partly Upheld Jan 2025
P-002303 — South West Yorkshire Partnership NHS Foundation Trust
Miss H complained the Trust's consultant psychiatrist changed her medication and refused to revert it, which she believes led to her mental health deteriorating and being sectioned.
NHS in England Upheld Nov 2023
P-002748 — Surrey and Sussex Healthcare NHS Trust
Mrs L complained the Trust incorrectly stopped her mental health medication during admission, delaying its restart and negatively impacting her mobility and mental health, prolonging her hospital stay.
NHS in England Jul 2024
P-002761 — A practice in the Hackney area
Miss P complained the Practice abruptly stopped her mother's medication without review, and then lied in its complaint response, which she believes led to her mother's death.
NHS in England Jul 2024
P-003121 — Cheshire and Wirral Partnership NHS Foundation Trust
Mr R complained the Trust stopped his Clozapine medication without an alternative plan, ignoring concerns and causing a severe 'rebound psychosis' which nearly killed him.
NHS in England Nov 2024
P-004419 — Greater Manchester Mental Health NHS Foundation Trust
Mr A complained about delays in preliminary checks and prescribing quetiapine, lack of medication review, and inappropriate discharge of his wife, causing her stress and anxiety.
NHS in England Nov 2025
Domestic Homicide Reviews(4)
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