Louise Rosendale

Tel 0161 748 2021    

                                                                                                             Email: flixtonroad.mc@nhs.net                                                                        

132 Flixton Road

 Urmston  

Manchester
 M41 5BG

Private & Confidential 
Ms Alison Mutch
HM Senior Coroner
Coroner’s Court
1 Mount Tabor Street 
Stockport
SK1 3AG

 28 May 2025

Dear Ms Mutch,

Response to Regulation 28 Report into the death of Louise Danielle Rosendale

Thank you for your letter and for sharing with us the findings from the recent inquest, along with the matters 
of concern outlined in the Regulation 28 Report. 

We would like to begin by expressing our sincere condolences to the family and loved ones of Ms 
Rosendale. We recognise that this has been an extremely difficult and distressing time, and we are deeply 
sorry for their loss. As a practice, we fully acknowledge the emotional impact that events such as these can 
have on those affected.

We welcome the opportunity to reflect on the circumstances of this case and to respond constructively. 
We have carefully considered the issues raised in the Prevention of Future Deaths report, particularly 
those relating to the prescribing and administration of opiates. 

As part of our commitment to learning and improvement, we have undertaken a review of our current 
practices and will provide additional education and guidance to our staff to reinforce safe prescribing, 
monitoring, and administration of these medications. We are making changes which are relevant to 
addressing the concerns. 

Background

1. Regulation 28 Report into the death of Louise Danielle Rosendale

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                                                                                                                 Tel 0161 748 2021    

                                                                                                             Email: flixtonroad.mc@nhs.net                                                                        

132 Flixton Road

 Urmston  

Manchester
 M41 5BG

Our Response
To each of the matters of concern are provided as follows: - 

Concern - Prescribed Opiates

The inquest heard that Ms Louise Rosendale 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.  

Response to Concern

Ms Rosendale (our patient) had passed away, the review by the coroner noted that there was historic high 
use of opioids. Ms Rosendale was taking 120mg of Morphine via tablet form and taking oramorph also. 
Ms Rosendale had been taking historically high doses of opioids before becoming a patient at Flixton Road 
Medical Centre, due to symptoms of severe abdominal pain and had seen general surgeons and 
gastroenterologist who confirmed the high dose opioid use to control Ms Rosendale’s pain. 

Ms Rosendale was taking 120mg of oral morphine through tablets and liquid morphine when required. Ms 
Rosendale’s patient history stated there were several admissions to casualty with severe pain. 

Ms Rosendale transferred to Flixton Road Medical Centre in December 2019 following the closure of her 
previous GP practice, along with the doctors who had been caring for her. She continued to be seen 
regularly for general health reviews throughout 2020. In May 2021, she had a medication review with her 
regular GP, which included management of her mental health condition and medications prescribed by the 
mental health team.

Ms Rosendale was reviewed in the gastroenterology clinic in March 2022, where a continued diagnosis of 
pancreatitis was made. Despite ongoing severe pain, no changes were made to her opioid medication. At 
this time, she was also under haematology for chronic anaemia and cardiology for arrhythmias; all involved 
specialists were aware of her medications and raised no concerns.

In June 2022, a GP medication review confirmed the continuation of high-dose opioid treatment as per 
gastroenterology advice. Ms Rosendale reported that only by taking oral morphine sulfate (120mg daily) 
and Oramorph as needed, did she gain some relief. The risks of high-dose opioid use were discussed.

In September 2022, the Primary Care Network pharmacist switched her medication to Zomorph. A follow-
up review in October 2022 resulted in no further changes. That same month, she attended Wythenshawe 
Hospital with severe abdominal pain. A CT scan showed no acute changes, and she was treated with 
additional opioids. A referral to gastroenterology was made.

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                                                                                                                 Tel 0161 748 2021    

                                                                                                             Email: flixtonroad.mc@nhs.net                                                                        

132 Flixton Road

 Urmston  

Manchester
 M41 5BG

In March 2023, the medicines management team reviewed her prescription after she reported a lost bottle 
of Oramorph, later confirmed to have been mistakenly discarded by her father.
She was seen in August 2023 for ENT concerns and diagnosed with a deviated septum. Blood tests showed 
no abnormalities. In September 2023, she attended her annual health check with the nurse.

In November 2023, Ms Rosendale sustained a fractured clavicle after a fall and received treatment. She 
was reviewed by a GP in March 2024 for concerns about low B12, and blood tests were ordered.

In July 2024, the practice pharmacist conducted a medication review. Ms Rosendale later reported 
misplacing some Zomorph; the amount was calculated and replaced. A follow-up consultation reinforced 
the importance of adhering to the prescribed dose. Ms Rosendale stated her father assisted with her 
medication. She was advised not to take additional opioids beyond the prescription.

She was offered a face-to-face appointment on 18 September 2024, but did not respond. On 20 
September, she contacted the surgery regarding ankle swelling and was seen the same day.

Flixton Road Medical Practice was notified of Ms Rosendale’s death on the 25th of September 24. The 
cause of death was respiratory infection, but the pathologist noted the high levels of opioids in the patient 
postmortem results. There was also codeine which was not prescribed by the practice and the combination 
of both medications added to the respiratory depression. 

As part of the practice’s commitment to continuous learning and patient safety, a comprehensive review of 
opioid prescribing was undertaken. This included a revision of the opioid prescribing policy in line with 
current clinical guidelines, alongside the introduction of mandatory training for all prescribers to support 
safer opioid use. An audit of high-risk prescribing was completed to identify areas for improvement and 
ensure appropriate monitoring. Electronic safety alerts within the prescribing system were optimised to 
support clinical decision-making at the point of care. Structured medication reviews were reinforced as a 
routine part of ongoing care, particularly for patients on long-term or high-dose opioids. In addition, a 
standardised communication protocol was developed to ensure consistent, clear, and timely 
documentation and coordination between clinical teams involved in patient care. These actions aim to 
strengthen prescribing safety, enhance patient outcomes, and support a culture of continuous quality 
improvement.

To ensure that the learning from this case is fully embedded across our practice, we have developed an 
action plan to address the concerns raised, which is enclosed with this response. Key elements of our 
learning dissemination include publication on our internal learning platform (TeamNet), briefing sessions 
with the clinical team, and structured reflection during team meetings.

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                                                                                                                 Tel 0161 748 2021    

                                                                                                             Email: flixtonroad.mc@nhs.net                                                                        

132 Flixton Road

 Urmston  

Manchester
 M41 5BG

On reflection, several areas have been identified where care could have been improved. Earlier 
identification of risks associated with long-term high-dose opioid use may have prompted more timely 
interventions. Greater patient involvement in decision-making could have supported shared understanding 
and safer management plans. There was limited external input from specialist services in reviewing 
ongoing opioid prescribing, and an absence of a formal monitoring framework meant that risk mitigation 
strategies were not consistently applied. Resource constraints also impacted the ability to implement more 
proactive, structured reviews. Opportunities were missed for more proactive monitoring of opioid use, 
supported by a clear and structured communication protocol across the clinical team. Additionally, ongoing 
training in opioid safety and polypharmacy was not embedded consistently across the team. Structured 
medication reviews should have been undertaken more frequently and in a multidisciplinary context. 
These findings have guided recent improvements aimed at enhancing clinical practice and ensuring safer 
patient care.

A more robust process for prescribing high-dose opioids has now been introduced to ensure greater 
clinical oversight and patient safety. This includes a clear prescribing protocol that outlines thresholds for 
escalation, mandatory documentation of clinical rationale, and multidisciplinary involvement in decision-
making. All high-dose opioid prescriptions are now subject to regular structured medication reviews, with 
clearly defined intervals and oversight by both GPs and clinical pharmacists. Electronic prescribing systems 
have been updated to include enhanced safety alerts, specifically highlighting high opioid use, with a safety 
message now embedded in our EMIS clinical system to prompt prescribers at key decision points.

Additionally, any new initiation or dose escalation of high-level opioids requires a documented risk-benefit 
discussion with the patient, including exploration of alternative pain management strategies. This process 
is supported by ongoing staff training in opioid safety and polypharmacy and monitored through regular 
audits to ensure compliance and continuous improvement.

We have included the following documents for your consideration with our response.

Investigation Action Plan

1.
2. Regulation 28 – Response Final
3. Review of Opioids Treatment for non-Palliative Patients
4. Teamnet Page Opioids and Pain Management
5. Opioids Prescribing Protocol
6. SEA
7. Audit

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                                                                                                                 Tel 0161 748 2021    

                                                                                                             Email: flixtonroad.mc@nhs.net                                                                        

132 Flixton Road

 Urmston  

Manchester
 M41 5BG

In addition, we will share the key findings and learning points with our Primary Care Network (PCN) 
colleagues and across other practices within the Trafford area to support wider system learning and 
reinforce safe practice in the prescribing and management of opiates.

To ensure the effectiveness of the actions taken and to support continuous improvement, we will 
implement follow-up audits to monitor compliance with revised protocols and safety measures related to 
opiate prescribing. The audit results and learning will be reviewed at our practice meeting, where we will 
strive to ensure all new processes are acknowledged and embedded by all the clinical team.

Thank you once again for providing the practice with the copy of the regulation 28 report for our attention 
and remedial action.

Yours sincerely, 

Partner
Flixton Road Medical Centre

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E: 

Date: 24 June 2025

Private & Confidential

Ms Alison Mutch
Senior Coroner for the area of Manchester South
Coroner's Court
1 Mount Tabor Street
Stockport
SK1 3AG

Sent by email to:

Dear Ms. Mutch

Re: Regulation 28 Report to Prevent Future Deaths - Louise Danielle Rosendale

Thank you for your Regulation 28 Report dated 30 April 2025 regarding the sad death of Louise Danielle 
Rosendale. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin 
by offering our sincere condolences to Ms. Rosendale’s family for their loss.

Thank you for highlighting your concerns during the inquest which concluded on the 17 March 2025. On 
behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. 
We recognise it is very important to ensure we make the necessary improvements to the quality and 
safety of future services.  

During the inquest you identified the following cause for concern:

Louise Rosendale 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. The inquest was told that 
she had been identified as a patient on a long-term opiate prescription in 2022. The next action 
had been a pharmacy review in July 2024. There was no evidence of long-term detailed planning 
or oversight of these patients within the practice.

NHS GM has undertaken an investigation into the cause for concern. As the GP practice responsible for 
Ms. Rosendale’s care, Flixton Road Medical Centre has provided a comprehensive response, and I 
understand that their response has been shared directly with you. The practice has shared their 
response with NHS GM, and I have included this and the associated documentation at Appendix 1 to this 
letter. 

4th Floor, Piccadilly Place, Manchester  M1 3BN  

Tel: 0161 6257791  www.gmintegratedcare.org.uk

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 NHS GM (Trafford locality) Medicines Optimisation team have reviewed your report and the cause for 
concern and have provided information on the expectation of care for patients prescribed opioids, work 
underway in the locality to reduce harm from opioids and plans for improvements in the future. 

GP practice expectation regarding review of patients prescribed opioids. 

Since October 2020, there has been a requirement, as part of the PCN Direct Enhanced Service (DES) 
contract, for GP practices to proactively identify and prioritise for structured medication review (SMR) 
patients using one or more potentially addictive medications from the following groups: opioids; 
gabapentinoids; benzodiazepines; and z-drugs. However, the PCN DES also states that the number of 
SMRs that a PCN is required to offer will be determined and limited by their clinical pharmacist capacity. 

Work undertaken in the NHS GM Trafford Locality

The Trafford locality Medicines Optimisation Team have undertaken several actions with the aim of 
reducing harm from opioids. 

One of the pharmacists in the team leads on opioid risk reduction and pain management, collaborating 
with colleagues to share good practice and implement strategies for opioid risk reduction. This includes:
• Taking part, along with a pharmacy technician from the Trafford team, in the Medicines Safety 

Improvement Programme (MedSIP) breakthrough series collaborative which aims to implement a 
whole system approach to high-risk opioid prescribing. This has resulted in sharing of good 
practice and closer working with other secondary and primary care colleagues across Greater 
Manchester. 

• Representing the Trafford Locality at the Greater Manchester Pain Collaborative which brings 
together stakeholders to identify and develop solutions to the challenges of prescribing pain 
medicines across Greater Manchester.

• Attending the local hospital trust’s Opioid Safety Group to facilitate primary and secondary care 
colleagues working together to reduce the harm from opioids. One of the current areas of work 
for this group is the implementation of the GM Communication Standards for Opioids at 
Discharge. 

• Attendance at trust-led case-based discussions regarding opioid prescribing to gain a better 

understanding of the challenges faced in secondary care and how these impact on primary care
• Working with colleagues from Manchester University to investigate and implement use of the new 
Safety Medication (SMASH) dashboard indicator which identifies patients prescribed opioids 
within 30 days of discharge from hospital. The aim of the indicator is to facilitate identification and 
review of patients to prevent harm from long term opioid use. 

• Collaboration with a colleague from another locality to produce a communication for primary care 
to highlight the risks from opioids used in chronic pain, encourage review of these patients and 
signpost to resources available on the Greater Manchester Pain Management Resources Hub.
• Discussion at regular meetings held with PCN clinical pharmacists to highlight the need to identify 
and prioritise patients prescribed opioids for structured medication reviews and ensuring they are 
aware of resources available to facilitate review, including the Greater Manchester Pain 
Management Resources Hub.

4th Floor, Piccadilly Place, Manchester  M1 3BN  

Tel: 0161 6257791  www.gmintegratedcare.org.uk

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 • Attendance at the Regional CD Local Intelligence Network meetings to ensure awareness of and 

learning from issues/incidents in other areas and share good practice. 

As well as continuing with the work detailed above, the following actions are planned in Trafford locality 
this year:

• Work with GP practices to increase use of the safety medication (SMASH) dashboard, including 

the new opioid indicator.

• Review by a pharmacy technician and pharmacist from the team of patients flagged by the 

SMASH opioid indicator and identify improvements that can be made to primary care review 
processes as well as feeding back, via the trust Opioid Safety Group, potential improvements to 
secondary care processes. 

• Work with colleagues in other GM localities to produce and implement standards for primary care 

review of patients discharged on opioids. 

• Provide data to GP Practices regarding their opioid prescribing, including high dose opioids, and 

•

ensure they are aware of resources available to facilitate review of patients. 
Increase awareness, and ensure information is readily accessible to GP practice clinicians, 
regarding local services available to support the review of patients on opioids, including pain 
clinic referral pathways and non-pharmacological support for pain management. 

• Collaborate with colleagues from other GM localities and secondary care pain clinics to explore 

the potential for multidisciplinary team review of complex patients on high dose opioids in primary 
care. 

NHS GM works in partnership across all locality Medicines Management teams and all learning is shared 
through the ICB for GM wide system learning. 

I hope that this responses assures you that NHS GM has responded to your report and will take positive 
steps to share learning. If you have any questions about this responses, please contact me.

Best wishes

4th Floor, Piccadilly Place, Manchester  M1 3BN  

Tel: 0161 6257791  www.gmintegratedcare.org.uk

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