Insufficient safeguards in long term opioid prescribing
Greater Manchester Integrated Care Board received 2 coroners' reports about this hazard between 16 Oct 2024 and 30 Apr 2025.
They came from 1 coroner. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“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.”
Original on judiciary.uk ↗ Greater Manchester Integrated Care Board responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“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.”
“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”
Stated timescale: October 2024
- 6 months laterClosely relatedConfidence 0.90 · high
“[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.”
Original on judiciary.uk ↗ Repeated from the earlier report:despiterisks
Greater Manchester Integrated Care Board responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Greater Manchester Integrated Care Board
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2024 → 2025Louise Rosendale6 months after Paul Clark · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient safeguards when prescribing opioids, specifically a lack of proper assessment or monitoring of patients receiving opioid medication.
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.”
Original on judiciary.uk ↗ 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.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“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
“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 · 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”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Greater Manchester Integrated Care Board at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2024 → 2025 | 0.67 | 0.05 | Closely related · 0.90 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.