Recurring concern

Failure to identify clinically significant medication risks

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First reported 30 Jul 2013•Latest report 3 Jun 2026

Definition

What this concern includes

Includes failures in medication review, reconciliation, prescribing or screening that concern recognising the clinical significance of a medicine, contraindication, interaction, toxicity, side-effect or existing medication.

Not included

Excludes failures to administer, monitor or supply medication where the concern is not specifically the identification of medication-related risk.
Excludes illicit or general drug-use hazards not tied to a medication-safety control.
Excludes generic failures to recognise symptoms or deterioration unless the report explicitly links them to medication-related risk.
Excludes generic communication, documentation or staffing deficiencies that are not dedicated to identifying medication risks.

Reports: 54
Individual concerns: 58
Date range: 2013–2026
Stated actions: 100

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care8

NHS England6

NHS Greater Manchester Integrated Care Board5

Care Quality Commission4

Medicines and Healthcare products Regulatory Agency4

NHS Surrey and Sussex Integrated Care Board3

Royal College of General Practitioners3

Betsi Cadwaladr University LHB2

General Medical Council2

Greater Manchester Health and Social Care Partnership2

Herefordshire and Worcestershire Health and Care NHS Trust2

Nursing and Midwifery Council2

Royal College of Psychiatrists2

Adelaide Medical Centre, London1

Alvaston Medical Centre1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

9 Apr2014
Inner South London
Concerns raised1
1. Lack of prescriber awareness of Gabapentin's rare side effect of precipitating diabetic coma
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Build the drug-safety review into day-to-day clinical practice.
  Stated by Guy'S and St Thomas' NHS Foundation TrustStated completed
AI-generated summary

Michael Samuel Ian Anthony · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Michael Samuel Ian Anthony was found dead in his flat on 8 May 2013 and died from diabetic ketoacidotic coma. He had a very high Gabapentin level, and concern was raised about whether Gabapentin was contraindicated for someone with severe Type 1 diabetes and whether prescribing doctors knew of its rare potential to precipitate diabetic coma.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of prescriber awareness of Gabapentin's rare side effect of precipitating diabetic coma
Wider context from the report
“(1) It was not known whether Gabapentin was contraindicated to be prescribed in the deceased, who suffered severe Type 1 diabetes, or whether the prescribing doctors were aware of the rare side effect of Gabapentin in precipitating diabetic coma. If they were not there would be a potentially avoidable risk to other patients. ”
Source location
Michael Samuel Ian Anthony · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Build the drug-safety review into day-to-day clinical practice.

Verbatim wording from the response
“Many thanks for your letter of 10th April last sent to both myself and ████████████████████████ in relation to the above deceased. We note and acknowledge receipt of the Regulation 28 report to prevent future deaths on the above addressed to myself and ████████████████████████. I have asked for full disclosure by email to the coroner’s office of the toxicologist report. In the meantime, we have asked for a review from the regional drug information service at Guy's. This is attached below and forms part of our reflection, learning and response.”

Source location
2014-0161-Response-by-Guys-St-Thomas-NHS-Trust
Page 1 · response
Published 9 April 2014
Open published response
26 Feb2014
Black Country
Concerns raised1
1. Failure to withhold insulin when blood sugars are dangerously low
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Bertram Theophilus HAMILTON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Bertram Theophilus HAMILTON was a long-term care-home resident who died shortly after receiving insulin despite a recorded blood sugar level of 1.6. Concerns included the nurse appearing not to know that insulin should not be given when blood sugar was so low, and concerns about the nurse's account of events not being supported by contemporaneous documentation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to withhold insulin when blood sugars are dangerously low
Wider context from the report
“I am concerned that the nurse in question appeared not to know that insulin should not be given to a person whose blood sugars were so low. In addition, I was concerned that the nurse was not frank and open in giving evidence to me and claimed that she had given Mr. Hamilton a sugary solution, that she had re-checked his blood sugar and gave the insulin only after the blood sugar level was high. None of the contemporaneous documentation, including documentation completed by the nurse herself, supported such a contention. ”
Source location
Bertram Theophilus HAMILTON · Prevention of Future Deaths report
Page 1 · concerns
Open source report
23 Aug2013
West Yorkshire (East)
Concerns raised1
1. Failure to account for self-harm and suicidal tendencies when supplying unsupervised medication
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

JILL FELICITY SINSON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jill Felicity Sinson had schizophrenia, an anxiety-related disorder, non-epileptic seizures, and a history of self-harm and suicidal tendencies. She was last seen alive on 3 September 2012 and was found lifeless at her home on 10 September 2012; life was pronounced extinct by paramedics. The concerns included inadequate GP monitoring, failure to review or refer her after a GP surgery consultation, insufficient consideration of her medical history when prescribing medication unsupervised, and failure to act appropriately on correspondence from her Consultant Psychiatrist.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to account for self-harm and suicidal tendencies when supplying unsupervised medication
Wider context from the report
“(3) The Deceased was prescribed a significant quantity of medication on a monthly basis, such medication being given in possession and unsupervised, without due consideration for the Deceased’s medical history of self-harm and suicidal tendencies, which history was recorded on the Deceased’s computerised medical records. ”
Source location
JILL FELICITY SINSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Jul2013
West Sussex
Concerns raised1
1. Delays in discontinuing Tramadol after onset of confusion
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Phillip Arthur Pratt · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Phillip Arthur Pratt died on 2 November 2012 at St Richards Hospital after a fall-related fracture, surgery, and a sudden deterioration attributed to bronchopneumonia. The report raised concerns about incomplete medication information, delayed consideration of alcohol detoxification, delayed discontinuation of tramadol after confusion developed, delayed shoulder X-rays, and the unavailability of requested additional nursing staff for a high-risk patient.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in discontinuing Tramadol after onset of confusion
Wider context from the report
“During the course of the inquest, ████████, Head of Nursing for St Richards Hospital, gave evidence in relation to a “Root Cause Analysis Investigation Report”. The stated purpose of the report was “To identify the root causes and key learning from an incident and use this information”. The report covered a number of areas of concern arising from the investigation. ████████ gave evidence to say that a number of practices and additional training have already been put in place to address some of the issues set out in the report. The matters of concern that I raise herein deal with issues raised in the report in respect of which standard action has not yet been taken. (1) On admission to hospital and at pre-assessment stage, there was a note of the patient’s medication but no note as to dosage of medication. The Report indicates no attempts were made to contact the patient’s GP or family to ascertain precise levels of medication; (2) As it was not expected the patient would remain in hospital for a protracted stay, the need for alcohol detoxification was not considered at an early stage and not reassessed when the reason for the patient’s admission changed; (3) The onset of agitation and confusion had been recognized, with a (4) There was a delay in discontinuing the prescription for Tramadol despite the onset of confusion which is one of the contra-indications of that medication; (5) There was a delay in x-raying the shoulder. The report comments (6) Requests were made for nurse special staff to monitor a high risk patient but extra staff were not available. ”
Source location
Phillip Arthur Pratt · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of prescriber awareness of Gabapentin's rare side effect of precipitating diabetic coma

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to withhold insulin when blood sugars are dangerously low

Concerns raised1

Failure to account for self-harm and suicidal tendencies when supplying unsupervised medication

Concerns raised1

Delays in discontinuing Tramadol after onset of confusion

Actions described in response 1