Recurance · prevention of future deaths reports
Pre-inquest brief
Insufficient safeguards in long term opioid prescribing
The earlier warning
Paul Clark · 16 Oct 2024 · Alison Mutch, Manchester South
“However despite the risks opioid painkillers presented to him he had been started in primary care on opioid based painkillers for reported pain. He had become addicted to them and took them at increasing levels topping them up with non-prescribed opioids.”
judiciary.uk/…/paul-clark-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Paul Clark (16 Oct 2024) · stated timescale: none stated
“Archwood Medical Practice have undertaken an audit of their patient records to identify all patients with a history of drug addiction. A 'pop up' alert will be added to each identified record to ensure that anyone consulting with a patient within this cohort is immediately aware of the history and can therefore consider this history within their clinical decision making.”
Stated action 2 · response to Paul Clark (16 Oct 2024) · stated timescale: October 2024
“We have recognised the importance of safety in repeat prescribing and the role that General Practice and Community Pharmacy have in this space. Through our Clinical Policy work we have A4 collaborated with the Royal Pharmaceutical Society and over the last year, I co-chaired a group to develop a New Repeat Prescribing Toolkit to improve safety and efficiency of repeat prescribing systems in general practices across England (the first of its kind in over 20 yrs). We launched this toolkit at our A”
What recurred
- 30 Apr 2025 · Louise Rosendale · Alison Mutch · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Paul Clark · 16 Oct 2024
“However despite the risks opioid painkillers presented to him he had been started in primary care on opioid based painkillers for reported pain. He had become addicted to them and took them at increasing levels topping them up with non-prescribed opioids.”
Later · Louise Rosendale · 30 Apr 2025
“[the deceased] had been prescribed opiates for many years despite the risks associated with long term opiate prescribing. The evidence before the inquest was that there had been very limited attempts to review the long term prescribing of opiates to her.”
What happened next
No web check of the stated actions has been published for this chain.