Glenn Lockwood

Attendance Note 

Person Attending: 

Attendance Date: 

Nature of Attendance: 

Client/Matter Number: 

Case Name: 

22 January 2024 

Recording of Coroner’s Summing up  

 - Inquest of Mr Glenn Lockwood 

Welcome back and thank you for bearing with me.  Apologies I took slightly longer and anticipated.  
These are my findings and conclusions for the purpose of the Inquest.  

Mr Lockwood had a known history of opioid dependence, spanning at least the last ten years 
according to the evidence of the GP, probably significantly longer, given what his family have told 
me today. 

He  was  engaged  with  drug  treatment  and  support  services  prior  to  his  hospital  admission  on 
14 April 2023.  He was prescribed opioid replacement therapy which was to be collected daily.   

In  addition  the  GP  confirms  that  Mr  Lockwood  was  diagnosed  with  anxiety  disorder  in  February 
2021 and depressed mood in December 2022.  I ought to say at this stage that the anxiety disorder 
diagnosis does pre-date February 2021 but the reason it is recorded as that date on the record is 
because that was when first registered with that practice.  Glen’s anxiety disorder was treated with 
Pregabalin  which  was  last  issued  probably  to  Mr  Lockwood  on  5  April  2023  and  the  depressed 
mood was treated with Sertraline, also last issued on 5 April 2023.   

The evidence suggests that Mr Lockwood’s Pregabalin prescription was first put in place as I have 
 reviewed his Pregabalin 
said, by his GP in Essex prior to his move to London in 2021.  
prescription during a telephone consultation with Mr Lockwood on 9 March 2021.  
 tells 
me  that  at  this  review  it  was  agreed  that  Pregabalin  would  be  added  to  Mr  Lockwood’s  repeat 
prescriptions because it appeared to control his anxiety symptoms well.  

In August 2021 
 received correspondence from Reset Drug and Alcohol Service which 
set  out  Mr  Lockwood  has  failed  to  collect  his  daily  opioid  replacement  therapy  for  a  number  of 
days,  and  reported  that  he  had  reverted  to  using  both  heroin  and  crack  on  a  daily  basis.    Reset 
advised the surgery to avoid “prescriptions of other opioid based medications without liaison with 
their  team  and  to  be  cautious  when  prescribing  other  medications  which  may  have  potential  for 
interaction as well care with regard to other medicines with potential for misuse”.   

Mr  Lockwood’s  next  review  took  place  on  15  December  2021  and  no  changes  appear  to  have 
  tells  me  that  Mr  Lockwood  continued  to  request  his 
been  made  to  his  medication.   
prescriptions  for  Pregabalin  on  a  monthly  basis  which  were  issued  accordingly.    No  additional 
contact was made with the Practice by Glenn for a number of months.   

On 24 June and 1 July 2022, the Practice attempted to contact Mr Lockwood by telephone to invite 
him to attend an annual routine substance misuse review.  Mr Lockwood did not answer either call 
but a voicemail was left for him on each occasion.  In addition a follow-up text message was sent 
to him on 1 July 2022.   

On  12  July  2022  the  Practice  received  an  Accident  and  Emergency  discharge  summary.  
Essentially  Glenn  had  been  treated  with  antibiotics  for  cellulitis  following  an  attempt  to  inject 
himself with 

but missing the vein in his leg.   

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  Client Confidential 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Glenn was seen in Accident and Emergency again on 22 September 2022 for a further episode of 
cellulitis  with  the  lower  limb,  and  a  further  course  of  antibiotics  was  prescribed.    The  Practice 
attempted to contact Glenn again on 24 October 2022 to invite him to a substance misuse review.  
There was no response on the voicemail that was left.   

The Practice received further correspondence from Reset on 3 November 2022.  The letter set out 
that Glenn had attended for an in-person review the previous day, when a plan was put in place to 
restart his Methadone because he had failed to engage previously, and the prescriptions had been 
withdrawn.    The  letter  also  confirmed  that  a  mental  health  risk  assessment  had  been  conducted 
and there were no reported thoughts of self-harm or suicide. 

Glenn attended the Practice on 7 December 2022 having requested a routine appointment.  During 
that appointment Glenn reported feeling withdrawn, suffering from social anxiety and experiencing 
poor sleep.  He disclosed at that appointment the smoking of cannabis and using heroin regularly 
albeit,  he  said,  at  lower  levels  than  he  had  used  in  the  past,  because  he  was  now  receiving 
Methadone from Reset once more.   

I  am  told  by 
daily.  He did not report any thoughts of suicide or self-harm.   

  that  his  Pregabalin  was  increased  at  that  point  to 

milligrams  twice 

Glenn  attended  a  follow-up  appointment  with 
  on  26  January  2023.    During  this 
appointment there appears to have been a degree of confusion about the level of Pregabalin that 
Mr Lockwood ought to have been taking.  
milligrams  three  times  daily,  instead  of  going  straight  back  to  300  milligrams  twice  daily.    I  was 
concerned regarding managing his ongoing anxiety yet I would not want him to risk issuing surplus 
medication to a patient with potential for misuse.”   

 states “It was agreed to change this to 

 also commenced Glenn on a prescription of 

 milligrams of 
At the same appointment 
Sertraline an anti-depressant.  This was the last time that Glenn was seen in the Practice despite 
continued  efforts  to  engage  him.    However  a  number  of  prescriptions  I  am  told  continued  to  be 
requested and issued by the Practice.  Exactly what was issued is not clear despite the fact that 
the  Practice  undertook  a  serious  event  analysis.    Further  correspondence  from  the  Practice 
appears to accept that there is some confusion and that the notes are not clear, and that a further 
serious event analysis is required.   

In  February  2023  Glenn  was  taken  to  Accident  and  Emergency  by  the  police,  following  an 
overdose of Temazepam and Diazepam.  Following a period of observation Glenn was discharged, 
and  the  discharge  summary  sent  to  the  Practice  confirmed  that  Mr  Lockwood  had  no  suicidal 
thoughts at that time.  Neither of these medications were prescribed to Glenn at the time.   

Reset  have  confirmed  in  the  report  to  me  that  Glenn  had  missed  three  consecutive  Methadone 
doses  in  February  2023.    Following  this  he  did  attend  a  face-to-face medical  restart  appointment 
 at Reset on 11 April 2023.  At that appointment he reported using approximately 
with 
  that  his  recent  hospital 
  daily.    He  also  told 
admission for a drug overdose was the result of an accidental overdose.  A urine drug screening 
test  was  conducted  by 

  and  Glenn  tested  positive  for  opiates, 

  grams  of 

millilitres on daily supervised consumption, to be increased over time to

 millilitres per day. 

  commenced  Glenn  on  an  initial  daily  Methadone  prescription  of 

I find that there is clear evidence that Mr Lockwood’s engagement with his GP and Reset Addiction 
Service was somewhat sporadic.  However, I note that there is no evidence to suggest that Glenn 
lacked  mental  capacity,  and  as  such  he  was  in  entitled  to  make  decision  not  to  engage  in 
treatment, even if those decisions later seemed unreasonable to others.   

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  Client Confidential 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 Another  thing  that  is  clear  both  from  the  medical  evidence  and  from  Glenn’s  own  disclosures 
during appointments, is that throughout 2022 and up to the time of his last admission to hospital in 
April 2023, Glenn had clearly relapsed into the misuse of drugs.  Those appear to have included 
more usual drugs for want of a better way of putting it, as well as illicitly obtained medication, that 
was ordinarily prescription only, such as the Diazepam referred to earlier.  

 of  the Royal  London  Hospital confirms that Glenn  was brought  to  Accident  and 
Emergency  on  14  April  2023  having  been  found  unresponsive  on  the  platform  of  Westferry  DRL 
station.    He  was  treated  for  a  suspected  heroin  overdose  and  moved  to  a  ward  on  the  eleventh 
floor.   

  states  the  treatment  seems  to  improve  Mr  Lockwood’s  condition,  and  his  condition 
improved further overnight.  
 confirms that Mr Lockwood was seen by doctors on up to five 
separate occasions during this short admission.  But despite this Mr Lockwood sought to discharge 
himself  from  hospital  on  the  basis  of  having  been  in  hospital  for  24  hours  without  having  seen  a 
doctor.    I  have  been  provided  with  a  copy  of  the  self-discharge  documentation  signed  by  Glenn.  
As set out by 
, Glenn wrote words to the effect that he wanted to self-discharge because 
he needed to go to the pharmacy and because he had not been seen by a doctor for 24 hours.  He 
reportedly says that he would return to A&E if his chest worsened.  But the evidence from 
is  clear that  there  is  no question  had  not  been  seen  by  doctors.   Indeed,  there  is  clear  evidence 
that  at  least  three  separate  doctors  had  seen  Glenn  numerous  times  throughout  that  short 
admission.   

I then move on to the events of 16 April 2023 which is when for a short time at least the evidence 
becomes much less clear.  What is clear from the London Ambulance Service records is that a 999 
call was made regarding Glenn on the afternoon of 16 April 2023, and the call was connected at 
13:41.  On arrival of the ambulance at 13.47 paramedics were met by someone who purported to 
be  a  friend  of  Glenn.    The  London  Ambulance  Service  documentation  advises  of  the  telephone 
number from which the 999 call was made.  However during the course of my investigation I have 
not been able to identify who made that call, because the number relates to an unregistered mobile 
telephone which was confirmed in the evidence of

, the Coroner’s Officer.   

The  response  time  of  the  ambulance  on  that  occasion  is  documented  at  less  than  six  minutes, 
which  is  well  within  the  target  response  time  set  for  Category  1  lift  threatening  emergencies.    I 
mention this simply because it answers one of the questions that you the family had asked me to 
consider.  

Whoever the mystery friend with Glenn was, they stayed with him and commenced CPR as per the 
instructions  provided  by  the  London  Ambulance  Service  call  handler.    It  was  evident  that  the 
numerous  paramedics  that  attended  Mr  Lockwood  worked  tirelessly  for  well  over  an  hour  to 
attempt to resuscitate, stabilise and convey Glenn to hospital.  

The further curious matter which needs to be mentioned at this stage is that the paramedics noted 
that Glenn’s temperature was 27.2⁰ Celsius and he was therefore hypothermic.  However, he was 
noted  to  be  in  a  warm  environment  and  in  appropriate  clothing.    As  far  as  the  paramedics  were 
concerned  there  was  no  obviously  clinical  answer  as  to  how  Mr  Lockwood’s  temperature  had 
dropped to such a level.  Unfortunately, having been unable to identify the potential witness to this 
fact, I cannot offer a definitive answer to that point either.  I note that initial documentation provided 
a suggestion that Glenn’s friend found him outside and then took him back inside before calling an 
ambulance.    While  this  is  possible,  and  it  is  also  possible  that  Mr  Lockwood  collapse  may  have 
taken place elsewhere, I can make no formal finding in that regard in the absence of any reliable 
evidence.    I  also  note  the  mismatch  in  the  evidence  between  what  paramedics  were  told  by  the 
mystery friend, and the view of 
 about the overdose that led to the hospital admission on 
14  April  2023.    The  friend  appears  to  have  told  paramedics  that  Glenn  had  overdosed  on 
Pregabalin, whereas 

 worked on the assumption that it had been a heroine overdose.  

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  Client Confidential 

 
 
 
 
 
 
 
 
 
 
 
 
 
 On  balance  I consider that  it  is  most  likely  to  have  been  a  heroin  overdose.    This  is  because 

 is clear that three doses of Naloxone were administered to seeming good effect, and I bear 
in  mind  that  Naloxone  had  previously  been  provided  to  Glenn  by  Reset  to  self-administer  in  the 
event of accidental overdose, it being an antidote to opiates such as heroin.  

In terms of Glenn’s admission at Royal London Hospital thereafter, I consider that there is little for 
me to say.  The medical evidence sets out in clear terms that Glenn’s prognosis was not good from 
the  outset,  due  to  the  length  of  time  he  was  in  cardiac  arrest.    He  was  showing  clinical  signs  of 
hypoxic brain injury.  Essentially following some improvement an attempt was made by the Adult 
Critical Care Unit to extubate Glenn but he was not able to sustain independent breathing at that 
time.   

Further medical and neurological reviews came up with the possibility of inserting a tracheostomy.  
However,  family  concerns  and  subsequent  medical  concerns  regarding  Glenn’s  minimally 
conscious state was such that the medical decision was made with the support of Glenn’s family 
that  tracheostomy  procedure  should  not  be  attempted.    The  decision  was  taken  again  with  the 
support of Glenn’s family to extubate him and place him on a palliative care pathway.  

Glenn sadly died on 2 June 2023.   

undertook  numerous  toxicological  tests  including  the  taking  of  hair  samples.   
proposed medical cause of death in the following terms: -  

  conducted  the  post-mortem  examination  on  behalf  of  the  Coroner  and  also 
  offers  a 

1a – hypoxic brain injury, multiple organ failure and bronchopneumonia following cardiac arrest.   
1b – mixed drug toxicity.  

The  proposed  cause  of  death,  if  accepted,  would  mean  that  the  underlying  cause  of  Mr 
Lockwood’s death was mixed drug toxicity.  

Given  the  lack  of  direct  evidence  to  suggest  that  Mr  Lockwood  took  any  form  of  drug  in  the 
relatively  brief  period  after  his  self-discharge  from  hospital  on  15  April  2023,  this  is  something  I 
have considered particularly carefully to avoid jumping to conclusions.   

was  able  to  exclude  traumatic  injury  as  a  cause  of  the  hypoxic  brain  injury.    He  also 
notes  that  on  examination  Glenn’s  myocardial  damage  “did  not  appear  to  be  due  to  significant 
coronary artery atheroma”.  In addition, he notes that cocaine can be a known cause of myocardial 
fibrosis.   
  report  continues  “Toxicology  reveals  that  Mr  Lockwood  had  taken  several 
compounds  during  the  six  months  leading  up  to  his  death,  with  heroin  and  cocaine  at  levels 
associated  with  heavy  use.    Opiates  can  produce  collapse  or  indeed  fatality  if  taken  in  sufficient 
quantity due to severe respiratory depression/respiratory arrest.  Cocaine can cause cardiac arrest 
or sudden death irrespective of its concentration.”  

  is  clear  that  the  hypoxic  brain  injury,  multiple  organ  failure  and  bronchopneumonia  all 
developed  as  a  result  of  the  cardiac  arrest.    He  concludes  in  light  of  the  toxicology  results  “It  is 
therefore  more  likely  than  not  that  drug  use  and  subsequent  toxic  effects  are  responsible  for  the 
cardiac arrest, either directly on the vital controlling centres of the brain, or indirectly via an action 
on the heart or coronary artery”.   

I see no reason to question the logic and medical reasoning employed by 
 and therefore 
accept his proposed cause of death.  In doing so I have additionally borne in mind Mr Lockwood’s 
self-discharge  the  day  before  his  cardiac  arrest  in  which  he  wrote  of  his  need  to  go  to  the 
pharmacy.   This indicates that having spent approximately 24 hours in hospital, Glenn was likely 
experiencing  withdrawal  from  opiates  and  wishing  to  obtain  his  methadone  prescription  and 

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  Client Confidential 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 possibly  take  other  substances  which  by  his  own  admission  a  few  days  earlier  at  the  Reset 
appointment, on 11 April 2023, he was taking on a daily basis.  

Turning then to the formal Record of Inquest I record as follows: -  

Box 1:  Name of the deceased: 

Glenn Anthony Lockwood.  

Box 2:  Medical cause of death – 

1a.  Hypoxic  Brain  Injury,  multiple  organ  failure  and  bronchopneumonia  following  cardiac 
arrest.  

1b. mixed drug toxicity.  

Box 3:  How, when and where the deceased came by their death:   

Glenn Lockwood was admitted to hospital on 14 April 2023 following a suspected heroin 
overdose.  On 15 April 2023 he self-discharged from hospital against medical advice.  On 
16 April 2023 Mr Lockwood had an out of hospital cardiac arrest.  He was admitted to the 
Royal London Hospital and despite treatment he died in hospital on 2 June 2023.  

Box 4 – Coroner’s conclusion as to death: 

Drug related death.  

Finally,  I  considered  whether  my  duty  to  issue  a  report  aimed  at  preventing  future  death  is 
engaged.  In my view it is.  I will be issuing a report to the Limehouse Practice on the basis that the 
evidence  of  their  Serious  Event  Analysis  provides  insufficient  reassurance  that  practices  and 
procedures  surrounding  the  prescribing  and  documentation  of  medication  to  patients  has  been 
sufficient addressed.   

You  as  a  family  will  also  be  provided  with  a  copy  of  my  report.    The  law  also  states  that  the 
Practice has 56 days to respond to the report.  

That concludes the Inquest and all that remains if for me to offer you my sincere condolences for 
your loss.  

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  Client Confidential

THE LIMEHOUSE PRACTICE 

GILL STREET HEAL TH 

11  GILL STREET,  LONDON  E14  8HQ  TEL:  020 7515 2211 

EMAIL: THCCG.limehouse@nhs.net 

29th  January 2024 

Mr Ian Potter 
HM Assistant Coroner 
Inner North London 
Poplar Coroner's Court 
127 Poplar High Street 
London 
E14 OAE 

Dear Mr Potter, 

Regulation 28  Report to Prevent Future Deaths 

I write on  behalf of the partners of the Limehouse Practice to  respond to your Prevention of 
Future Deaths Report dated  17 November 2023. 

Firstly,  the partners and  I would like to offer our condolences to Mr Lockwood's family following 
his sad death. 

The Limehouse Practice serves a population of around  11,500 patients in Tower Hamlets, 
looking after a diverse group of patients, with  high rates of poor mental health and often facing 
significant economic adversity. A  particular characteristic of the practice is that it also serves a 
large number of hostels,  including the largest women's hostel  provision in the borough,  as well 
as a refuge for south Asian women,  a supported  living facility supporting adults with  learning 
difficulties.  Several other hostels within the Practice area provide accommodation for a large 
number of adults with  high  rates  of substance misuse,  a history of trauma and adversity,  and 
facing  poor mental health  and  psychosocial challenges. 

As a Practice we have worked for many years along with the local drug and alcohol service to 
provide excellent care for our patients who face difficulties with drug and alcohol use.  The 
experience of the partnership and team  at the  Limehouse Practice supports this work. 

Opiate substitute treatment is only prescribed by doctors within the practice who have completed 
at least part 1 RCGP substance misuse training,  and this is something we encourage all  doctors 
at the Practice to achieve. 

We operate a personal list system  and each prescribe opiate substitute therapy to the patients 
on  our own list to ensure continuity or care.  We also believe the continuity of personal lists 
assists in the safe management of high risk and complex patients within the  Practice. 

We also have a substance misuse key worker employed by RESET,  the local drug and alcohol 
service, who operates a satellite clinic at the Practice.  We only prescribe opiate substitute 
therapy to patients as part of shared care with  RESET. 

We have 2 network employed pharmacists based at the Practice who have supported us in 
monitoring high  risk drug prescribing,  including prescribing of drugs with a potential for abuse. 

There are four partners and four salaried GPs at the Practice.  Three of the partners are GP 
trainers and also have other roles  outside the Practice.  I have a special  interest in  alcohol and 

 
 
 
 
 
 
 
 
 
 
 THE LIMEHOUSE PRACTICE 

GILL STREET HEALTH 

11  GILL STREET, LONDON  E14  8HQ  TEL:  020 7515 2211 

mEMAIL: THCCG.limehouse@nhs.net 

substance misuse,  having completed part 1 and 2 RCGP substance misuse training.  I am the 
locality lead for primary care drug and alcohol  management,  supporting local  practice teams in 
managing patients with drug and alcohol problems and providing  physical health checks for this 
vulnerable patient group.  I also train GPs and other primary care team members in  alcohol 
management in  primary care as an  approved alcohol trainer for the RCGP. 

We note that the conclusion of the inquest was that Mr Lockwood's death was a drug related 
death, the medical cause of death being: 

1 a - hypoxic brain  injury,  multiple organ failure  and  bronchopneumonia following  cardiac arrest. 
1 b - mixed drug toxicity. 

We also understand that you found that the overdose that led to Mr Lockwood's admission to 
hospital on  14 April 2023 was like to have been a heroin overdose. 

We have and continue to consider the concerns raised  seriously and respond to the two 
concerns raised  and summarised  below: 

1.  That the evidence you  received during the inquest did  not reassure you that sufficient steps 
were taken for signs of Pregabalin abuse,  particularly in  a patient with  known  history of drug 
abuse. 

2.  The statement from  Mr Lockwood's named GP alluded to the fact that there were possible 
record  keeping issues surrounding Mr Lockwood's prescriptions for Pregabalin. A  Serious 
Event Analysis (SEA) was conducted  but,  as there were errors in the original SEA,  we 
decided that the SEA needed to be re-opened and revisited.  You were not reassured that 
the relevant risks have been fully explored and acted upon. 

We have undertaken a further SEA,  and this has been  completed with agreed actions. 

Prescription of Pregabalin and monitoring for signs of abuse: 

We are aware of the recommendation in the British  National Formulary that Pregabalin should be 
monitored for signs of abuse. 

All  patients have medication reviews and those patients who are known to have problems with 
substance misuse are be invited to  have an  annual substance misuse health check which would 
involve physical  health checks carried  out by an  HCA/ nurse followed  by a comprehensive 
review of physical and  mental health by the registered GP. 

We were aware of the recommendations made by CGL (the drug treatment provider at the time) 
in  August 2021  that care should  be taken when prescribing other medications for Mr Lockwood 
that may have misuse potential, for example Pregabalin.  Since prior to registering  at the 
Practice in  2021,  Mr Lockwood had  been receiving  a prescription of Pregabalin, which was 
issued at 4 weekly intervals.  This continued with the  knowledge and  recommendation of RESET, 
who were ma·naging the patient's substance misuse including  prescribing him  methadone. 

Until  December 2022,  Mr Lockwood continued to receive  prescriptions for Pregabalin at four 
weekly intervals when the duration was changed to two weekly.  There had been no previous 
incidences of early requesting  of Pregabalin,  or concerns that the patient was misusing or over-
using this medication. 

 
 
 
 
 
 
 
 
 
 THE LIMEHOUSE PRACTICE 

GILL STREET HEAL TH  CENTRE 

11  GILL STREET,  LONDON  E14  8HQ  TEL:  020 7515 2~11 

EMAIL: THCCG.limehouse@nhs.net 

Between December 2022 and  26 January 2023 there were further reviews of the Pregabalin. 

In  December 2022 Mr Lockwood was reviewed  and  he  reported  increased anxiety symptoms. 
The GP suggested this dose increase as a response to Mr Lockwood's reported increased 
anxiety.  The dose is within the  BNF recommended  ranges,  and this medication was prescribed 
for anxiety,  one of the licenced  indications for this drug.  This does therefore seem a reasonable 
course of action.  That doctor reduced the length of the prescription to two weeks instead of the 

- usual four weeks. 

There was a mistaken concern on  17 January 2023 that Mr Lockwood had requested the 
prescription for Pregabalin early (after two weeks rather than four weeks).  It would  be  · 
appropriate to reject any ~rescription,  particularly for a controlled drug or a drug with potential for 
addiction,  if this is  requested  early,  to avoid the  patient over-using and  being exposed to the risks 
of overdose.  This would  have been  in  accordance with the recommendations of CGL in August 
2021  to  monitor for signs of abuse. 

As we  have identified in  the SEA,  between  17 January 2023 and  26 January 2023 three doctors 
were  involved  in  reviewing  and  altering the  prescription for Pregabalin with a view to reducing the 
tablet burden  and  address the reported  increasing anxiety.  Unfortunately, there was some 
confusion  and  lack of clarity about the prescribing  (which  I will  deal with further below). 

After 26 January 2023 Mr Lockwood was  not seen face to face again  at the  Practice prior to  his 
death on  2 June 2023,  although the  Practice made 4 attempts to contact him  to  invite him  (on 
three occasions for a substance misuse health check,  which would  involve physical health 
checks carried out by an  HCA / nurse followed  by a comprehensive review of physical and 
mental health (including an  assessment of abuse of the medication) by the registered GP,  and 
on  one occasion to invite him for immunisation) in  the intervening period.  He did continue to 
receive  his Pregabalin prescriptions at regular 4 weekly intervals. 

We were also made aware that Mr Lockwood  had been  admitted to hospital on  16  February 
2023 having taken an  overdose of clonazepam  and  diazepam. We attempted to contact Mr 
Lockwood 
on  24  February 2023 and  6 March 2023 but the phone did  not connect. 

Record  keeping  issues 

As  part of the SEA we  have established that the reasons for the change in  the dose and the 
frequency of the prescription of Pregabalin between December 2022 and January 2023 was not 
clearly documented in  the  records meaning that there was an  element of confusion for both the 
reviewing GPs and,  most likely,  Mr Lockwood. 

Action taken  by the  Practice 

As  set out in  the SEA we  have taken the following steps to address the concerns which you  have 
identified: 

1.  We will ensure 3 monthly face to face  reviews for patients on  Pregabalin,  gabapentin, 

benzodiazepines,  oxycodone and  other dependence inducing  medications. 

2.  We  are carrying out a search to  identify all  patients on  Pregabalin/ diazepam or similar 

medications who are also prescribed opiate substitute treatment,  either at RESET or in  shared 
care.  We will  carry out a medication review for those patients and  discuss with  RESET and 

 
 
 
 
 
 
 
 
 
 THE LIMEHOUSE PRACTICE 

GILL STREET HEALTH 

11  GILL STREET,  LONDON  E14  8HQ  TEL:  020 7515 2211 

EMAIL: THCCG.limehouse@nhs.net 

the possibility of them  prescribing  of opiate substitute medication as well  as other medications 
with  potential for dependence if appropriate. 

3.  If any changes are made in  doses of medication or tablet strength,  this must be documented 
in  EMIS consultation notes so there is a clearly identifiable rationale for any change.  Patients 
should also be notified of any change in  drug dosage / tablet strength. 

4.  Protected  Learning Time is to be used to provide refresher training to all  prescribers about 

EMIS prescribing function  and  how to view previous medication issues/ amendments, as well 
as further training  on  prescribing drugs with  potential for dependence.  I have contacted the 
CGL/RESET consultant and am awaiting  a response from them about agreeing a date for 
training. 

5.  All  prescribers to  undergo further training  on  prescribing  drugs with  potential for dependence. 

Unfortunately, we did  not receive any further information from the hospital or notification of Mr 
Lockwood's death until a letter dated 30 June 2023 was received from the Senior Coroner's 
officer on  3 July 2023. At that stage we were unaware of the medical cause of death to allow us 
to consider arranging for an  SEA to be carried out.  We only received details of the medical cause 
of death following the conclusion of the inquest. We have taken steps to ensure that requests for 
reports and correspondence with the Coroner's office are brought to the attention of the partners 
so that we can  ensure that all  matters relevant to the Coroner's investigation and  inquiry are 
dealt with  and that, where appropriate, we can arrange for an  SEA to be  undertaken in  a timely 
manner. 

I hope this information provides you with reassurance that your concerns about the risk of future 
deaths have been addressed. 

GP Partner & on  behalf of: 

 - GP Partner 

 - GP Partner 

 - GP Partner