Recurring concern

Failure to identify clinically significant medication risks

First to latest report 30 Jul 2013 — 3 Jun 2026

Reports that mention this concern
54
Times this concern has been raised
58
Stated actions linked to this concern
100

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.

What is 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 and published responses 54 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    Marjorie Cybil Bassendine · 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

    Marjorie Cybil Bassendine, aged 98, suddenly collapsed while eating breakfast at her care home on 2 October 2015 and died despite resuscitation. The inquest recorded cardiac arrhythmia, long QT syndrome and therapeutic drug use as the medical cause of death. The principal concern was that multiple medications capable of prolonging the QT interval had been prescribed without assessment of her cardiac status, including an ECG, or regular ECG monitoring.

    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 recognise the QT-prolonging potential of multiple psychotropic medication

    Wider context from the report

    “1. To recognise use of multiple psychotropic medication has the potential to prolong the QT interval. ”

    Source location

    Marjorie Cybil Bassendine · Prevention of Future Deaths report
    Page 2 · 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

    Publicise the medication-safety concerns to Royal College of Psychiatrists members and fellows.

    Verbatim wording from the response

    “Actions planned by the Royal College of Psychiatrists:”

    Source location

    2016-0424-Response-by-RCPSYCH
    Page 1 · response
    Published 19 February 2017

    Open published response

    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

    Determine how best to raise the medication-safety concerns with old-age psychiatrists.

    Verbatim wording from the response

    “Actions planned by the Royal College of Psychiatrists:”

    Source location

    2016-0424-Response-by-RCPSYCH
    Page 1 · response
    Published 19 February 2017

    Open published response

    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

    Review continuing medical education initiatives to ensure comprehensive coverage of the medication-safety issue in College materials.

    Verbatim wording from the response

    “3. We will review our continuing medical education initiatives to ensure that this issue is comprehensively covered in RCPsych material;”

    Source location

    2016-0424-Response-by-RCPSYCH
    Page 2 · response
    Published 19 February 2017

    Open published response

    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

    Review the product information for olanzapine, mirtazapine and indapamide to assess QT-prolongation warnings.

    Verbatim wording from the response

    “We have reviewed the product information (Summary of Product Characteristics [SmPC] and Patient Information Leaflet) of olanzapine, mirtazapine and indapamide and are satisfied that all three contain appropriate warnings regarding the risk of QT prolongation, particularly when used with other medication that also causes QT prolongation. Details of the relevant warnings are included in Annex A.”

    Source location

    2016-0424-Response-by-MHRA
    Page 1 · response
    Published 19 February 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing product warnings appropriately address QT-prolongation risks, so no regulatory changes are currently proposed.

    Verbatim wording from the response

    “We have reviewed the product information (Summary of Product Characteristics [SmPC] and Patient Information Leaflet) of olanzapine, mirtazapine and indapamide and are satisfied that all three contain appropriate warnings regarding the risk of QT prolongation, particularly when used with other medication that also causes QT prolongation. Details of the relevant warnings are included in Annex A.”

    Source location

    2016-0424-Response-by-MHRA
    Page 1 · response
    Published 19 February 2017

    Open published response

  2. Blackpool and the Fylde

    AI-generated summary

    Barry THOMPSON · 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

    Barry Thompson, an insulin-dependent diabetic, died on 27 February 2016 while a patient on the Acute Medical Unit, after being admitted with sepsis from diabetic foot ulcers and hyperglycaemia. The report identified concerns about failure to provide insulin, fluids, adequate monitoring, antibiotics and medical review, as well as inaccurate and incomplete records and ineffective information sharing during transfer between departments.

    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 assess the significance of patients’ existing comorbidity medication

    Wider context from the report

    “(3) Monitoring patients’ basic needs. There was difficulty encountered giving Mr Thompson saline by way of a drip. He was given an infusion of 1 litre over 4 hours at 17.30. At 23.00 it was found that the original cannula had become detached but the remaining fluid in the sac was 700mls. Mr Thompson’s bed was wet with saline fluid. He did not therefore receive the intended dose. He was not given a further injection of antibiotics 6 hours after the first nor was he written up for it. He was not given insulin. He does not appear to have been given any food whilst a patient or adequate fluid balance charts maintained. He was not seen by a doctor on the AMU. He was on a range of medication on admission to hospital for co-morbidities. The importance of this or otherwise was not assessed by staff. ”

    Source location

    Barry THOMPSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Black Country

    AI-generated summary

    Kinga Cieciorska · 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

    Kinga Cieciorska, a 16-year-old girl with complex medical needs, was taken to hospital with abdominal pain and distension. She was diagnosed with constipation and discharged, but deteriorated overnight and died after being returned to hospital on 11 March 2016; the stated cause of death was peritonitis from a perforated gastric ulcer. Concerns included failure to investigate tachycardia and an abnormal ECG, failures in recording and transmitting clinical information, and failure to consider the significance of her medication.

    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 consider medication details and the significance of diclofenac

    Wider context from the report

    “3. It also emerged during the inquest that details of her medication including the significance of the drug, Diclofenac was not considered. One of the contra-indications of this drug for long term users is gastric ulcers. Many people take NSAIDs without having any side effects, but there's always a risk the medication could cause problems, such as stomach ulcers, particularly if taken for a long time or at high doses. ”

    Source location

    Kinga Cieciorska · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. East London

    AI-generated summary

    Mr Devindar Lal Seth · 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

    Mr Devindar Lal Seth, aged 94, suffered a fall, fractured his hip and underwent surgery before developing opiate toxicity after postoperative pain treatment. The opiate toxicity was not identified by ward staff until family members raised concerns, and there was also a delay in ventilation after he suffered aspiration. The report identified a lack of clear guidance for ward staff about the risks and side effects of opiate medication in older orthopaedic patients.

    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 clear, accessible guidance for ward staff on opioid risks and side effects in orthogeriatric patients

    Wider context from the report

    “During the course of the evidence, it was confirmed that there is no clear guidance available to ward staff on the risk of opiate medications in orthogeriatric patients and side effects to look out for. I have been provided with the WHO Analgesic Ladder and the Guidelines for Acute Pain Management in Adults. The guidelines provide substantial amounts of information in relation to the contra-indications of NSAIDs. The only information relating to opioids in the Guidelines is that regular opioids can cause constipation. It is clear that none of the ward staff in this case recognised the effect that the opiate medication was having upon Mr Seth and I consider that it would be helpful for easily accessible guidance to be available for both nursing and medical staff. ”

    Source location

    Mr Devindar Lal Seth · Prevention of Future Deaths report
    Page 2 · 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

    Produce staff guidance on opioid medication risks, side effects and signs of opioid toxicity.

    Verbatim wording from the response

    “2. The Pharmacy department is producing guidance for staff relating to the risk of opiate medications, their side-effects and the signs of opiate toxicity.”

    Source location

    Davindar-Lal-Seth-Response
    Page 2 · response
    Published 26 February 2016

    Open published response

    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

    Cascade opioid-toxicity guidance to ward and medical staff and publish it in the hospital newsletter.

    Verbatim wording from the response

    “3. This guidance will be cascaded to all members of the ward and to medical staff and the communication manager will include the guidance as an article in the Newham University Hospital site newsletter.”

    Source location

    Davindar-Lal-Seth-Response
    Page 2 · response
    Published 26 February 2016

    Open published response

  5. Inner North London

    AI-generated summary

    David Alan White · 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

    David Alan White was admitted to hospital with significant pain from arterial vascular disease and later sustained two unwitnessed falls, the second causing fractures to his right hip and shoulder. He underwent emergency surgery and subsequently remained seriously unwell before dying on 26 June 2015. Concerns included the failure to record or act on reported confusion associated with Heparin, lack of supervision despite identified falls risks, and inadequate review and action on nursing records.

    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 record and act on Heparin-induced confusion

    Wider context from the report

    “(1) The effect of Heparin, in causing confusion, was not in the records, and therefore not acted upon. ”

    Source location

    David Alan White · Prevention of Future Deaths report
    Page 2 · 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

    Reinforce documenting drug allergies and adverse effects and escalate drug-related issues to senior clinical staff.

    Verbatim wording from the response

    “1. The members of staff have been reminded of the importance of adhering to the normal process of ‘documenting allergies and adverse effects’ regardless of how unique the reaction may be as in this case. This issue has also been discussed in the Renal Mortality and Morbidity meeting as a learning point for”

    Source location

    2015-0437-Response
    Page 1 · response
    Published 11 November 2015

    Open published response

  6. Worcestershire

    AI-generated summary

    Wayne Patrick O'NEILL · 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

    Wayne Patrick O'NEILL was a serving prisoner at HMP Long Lartin who collapsed in his cell and died on 2 January 2013. The inquest recorded respiratory failure, bronchospasm following ingestion of propranolol, and asthma as the medical cause of death. Concerns included the prescribing of propranolol despite asthma, the combination of psychotropic medicines with potential cardiac effects, and the failure to undertake an ECG before his death.

    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 asthma contraindications when prescribing propranolol

    Wider context from the report

    “(1) the evidence revealed that Mr O'Neill had died from one of two causes; either, as the jury found, he had taken propranolol illicitly which induced the broncho spasm that caused his respiratory failure. It is worth noting that Mr O'Neill had previously been prescribed propranolol and evidence was given at the inquest by a forensic psychiatrist that the fact it was contra indicated (given Mr O'Neill's asthma) appeared "to have been lost" to the prescribing clinicians at the time. The alternative cause of death was that Mr O'Neill died from acute cardiac failure induced by the combination of psychotropic medication prescribed to him including citalopram, Olanzapine and amitriptyline. An alert had previously been raised by the Medicines Healthcare Regulatory Authority warning against the prescribing of these drugs in combination. An attempt had been made to take Mr O'Neill off these drugs but subsequent clinician had re-introduced them. It was not clear from the evidence that when Mr O'Neill was screened in reception following his transfer from HMP Birmingham to HMP Long Lartin the significance of these combinations of medication was recognised. Expert evidence was heard during the cause of the inquest notably from ████████ a Cardiologist. He said there was a strong case for ECG traces to be performed on all prisoners in receipt of this medication. This would reveal whether there was any prolongation of the QT interval. The evidence revealed that an ECG trace had not been undertaken during the years that Mr O'Neill was an inmate at HMP Birmingham. A trace was arranged at HMP Long Lartin but had not taken place by the time of Mr O'Neill's death having only been requested as a matter of routine. The evidence suggested that the reason why the ECG was requested was due to an elevated pulse rate detected at the reception screen rather than recognition of the potentially toxic effects of the prescribed medication. Evidence was given that obtaining an ECG trace is a simply, cheap and straight forward matter. It would seem sensible, accordingly for all the prisoners in receipt of this combination of medication to undergo ECG traces as part of the reception screening process. ”

    Source location

    Wayne Patrick O'NEILL · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 recognise the toxic significance of medication combinations during reception screening

    Wider context from the report

    “(1) the evidence revealed that Mr O'Neill had died from one of two causes; either, as the jury found, he had taken propranolol illicitly which induced the broncho spasm that caused his respiratory failure. It is worth noting that Mr O'Neill had previously been prescribed propranolol and evidence was given at the inquest by a forensic psychiatrist that the fact it was contra indicated (given Mr O'Neill's asthma) appeared "to have been lost" to the prescribing clinicians at the time. The alternative cause of death was that Mr O'Neill died from acute cardiac failure induced by the combination of psychotropic medication prescribed to him including citalopram, Olanzapine and amitriptyline. An alert had previously been raised by the Medicines Healthcare Regulatory Authority warning against the prescribing of these drugs in combination. An attempt had been made to take Mr O'Neill off these drugs but subsequent clinician had re-introduced them. It was not clear from the evidence that when Mr O'Neill was screened in reception following his transfer from HMP Birmingham to HMP Long Lartin the significance of these combinations of medication was recognised. Expert evidence was heard during the cause of the inquest notably from ████████ a Cardiologist. He said there was a strong case for ECG traces to be performed on all prisoners in receipt of this medication. This would reveal whether there was any prolongation of the QT interval. The evidence revealed that an ECG trace had not been undertaken during the years that Mr O'Neill was an inmate at HMP Birmingham. A trace was arranged at HMP Long Lartin but had not taken place by the time of Mr O'Neill's death having only been requested as a matter of routine. The evidence suggested that the reason why the ECG was requested was due to an elevated pulse rate detected at the reception screen rather than recognition of the potentially toxic effects of the prescribed medication. Evidence was given that obtaining an ECG trace is a simply, cheap and straight forward matter. It would seem sensible, accordingly for all the prisoners in receipt of this combination of medication to undergo ECG traces as part of the reception screening process. ”

    Source location

    Wayne Patrick O'NEILL · 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

    Provide whole-nursing-team training to recognise medicines requiring ECG referral.

    Verbatim wording from the response

    “• Training will be provided to the whole Nursing team with regard to recognizing medicines that should indicate a referral for an ECG. These medicines might readily be recognized by a Mental Health Nurse but not necessarily by a Primary Care nurse.”

    Source location

    2015-0444-Response
    Page 2 · response
    Published 26 October 2015

    Open published response

  7. West Sussex

    AI-generated summary

    John Hills · 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

    John Hills, a resident of a nursing home, suffered fatal burns after his clothing and blankets caught fire while he was smoking in the conservatory. The report raised concerns about the failure to ensure he was wearing his fire-retardant apron and about insufficient awareness, communication and prevention of the fire risks associated with paraffin-based emollient creams such as Cetraben, particularly in community care settings.

    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 consider paraffin-emollient fire risk when prescribing

    Wider context from the report

    “(4) Mr Hills was clearly recorded (in his medical notes) as being a chronic smoker with acute bronchitis. He was also recorded as being a pipe smoker (in his medical records on 13/10/14) yet had a repeat prescription for Cetraben 500 gram being recorded on 11/09/14. There is nothing to evidence that any risk was considered or communicated by either the GP surgery or the prescribing pharmacy. ”

    Source location

    John Hills · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  8. Inner South London

    AI-generated summary

    Laurence Boyens · 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

    Laurence Boyens died in prison on 15 November 2012 from Methadone, Tramadol and Diazepam intoxication. The jury identified concerns about the combination and interaction of prescribed drugs, failures to monitor intoxication symptoms and blood pressure, and failures to suspend or withhold Methadone and Tramadol when signs of toxicity were present.

    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 stop medicines when Methadone toxicity is considered

    Wider context from the report

    “4. ████████ ████████ was represented at the inquest and the following evidence gave rise to concerns: • He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison. • When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam. • He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing. • He said that he did not know whether he should stop Methadone if the BP was low. • Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy. • At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered. • At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered. • He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives. ”

    Source location

    Laurence Boyens · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 assess drug interactions and cumulative effects before prescribing

    Wider context from the report

    “4. ████████ ████████ was represented at the inquest and the following evidence gave rise to concerns: • He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison. • When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam. • He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing. • He said that he did not know whether he should stop Methadone if the BP was low. • Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy. • At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered. • At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered. • He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives. ”

    Source location

    Laurence Boyens · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. North Wales (East and Central)

    AI-generated summary

    Christopher Paul Davies · 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

    Christopher Paul Davies was found unresponsive at home on 5 February 2014 and was verified dead that day; the inquest recorded accidental death, with the cause stated as clozapine poisoning. Concerns were raised that information about possible interactions between clozapine, caffeine and changes in smoking, and about warning signs of toxicity, had not been communicated to the deceased or Community Mental Health Team staff.

    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 communicate the effects of caffeine and smoking changes on clozapine levels

    Wider context from the report

    “He stated that although his son’s clozapine levels were being regularly monitored, at no point was he ever made aware of the possible interaction between caffeine or the cessation/reduction of smoking in relation to clozapine levels, nor was he made aware of the possible warning signs of toxicity. It was therefore felt that there should be greater emphasis placed on the sharing of this knowledge with users and with staff within the Community Mental Health Team. It was also felt that due to memory issues, patients should be regularly reminded of this information. ”

    Source location

    Christopher Paul Davies · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Blackburn, Hyndburn and Ribble Valley

    AI-generated summary

    Kathleen Cornthwaite · 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

    Kathleen Cornthwaite, aged 76, was an inpatient at Pendle Community Hospital when her tramadol prescription was increased after a fall causing a rib injury. The inquest concluded that she died of cardiorespiratory failure due to combined tramadol and fluoxetine toxicity. Concerns included the imprecise tramadol dose recorded, failure to account for her age, size and frailty, and failure to consider interactions with other prescribed medicines.

    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 a system to ensure consideration of other prescribed medicines when prescribing tramadol

    Wider context from the report

    “3. There was no system in place such that the doctor would appreciate the fact that in prescribing tramadol he or she ought to have had regard to other medicines being prescribed particularly in this case fluoxetine. ”

    Source location

    Kathleen Cornthwaite · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026