Recurring concern

Failure to reliably verify medication information during care assessments

First to latest report 30 Jul 2013 — 19 Mar 2026

Reports that mention this concern
6
Times this concern has been raised
6
Stated actions linked to this concern
18

What this concern includes

Includes failures of the assessment or review process to directly verify medication information, including checking medicines or medication records against the person's actual medicines and confirming the information needed by changing carers, school staff or other responsible caregivers.

What is not included
  • Excludes medication reconciliation across hospital or other care transitions where the concern is broader transfer and reconciliation of medication information rather than verification during an assessment or review.
  • Excludes medication prescribing, dosage, administration, supply or monitoring failures where medication information was reliably verified but a later control failed.
  • Excludes generic documentation, communication or care-planning deficiencies unless they directly cause failure to verify medication information during the assessment or review.
  • Excludes verification of non-medication care needs or equipment.

Reports and published responses 6 reports

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

  1. West Sussex, Brighton and Hove

    AI-generated summary

    John Malcolm FISHER · 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 Malcolm Fisher was admitted to hospital on 22 April 2025 with persistent focal seizures that developed into status epilepticus, and he died on 4 May 2025 after the seizures could not be controlled. The report raises concerns about inaccurate or incomplete medication information during transfers between community services and the omission of sodium valproate from the care agency’s medication record, resulting in six days without that 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

    Insufficient medication verification during care-needs assessment

    Wider context from the report

    “4) Coastal Homecare confirmed that an assessment of needs was carried out on 15 April 2025 by a supervisor attending Mr Fisher's home address. The UCR handwritten medication forms were used to digitally record the required medications into the Coastal Homecare electronic system. Initially I was told that photographs of the medication were taken as well but on checking no photographs could be recovered save one of skin creams. It is apparently not standard practice for photographs to be taken during this kind of assessment but during the inquest it was agreed this would be good practice in future to achieve greater clarity for daily carers who frequently change. ”

    Source location

    John Malcolm FISHER · 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

    Strengthen escalation pathways by referring complex medicines-reconciliation issues to senior clinicians and SCFT pharmacy support.

    Verbatim wording from the response

    “• Clear escalation pathways have been strengthened, including referral to senior clinicians and SCFT pharmacy support for complex medicines reconciliation.”

    Source location

    Response from Sussex Community NHS Foundation Trust
    Page 2 · response
    Published 26 March 2026

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    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 staff with Plexus shared-care-record access for real-time GP medication summaries.

    Verbatim wording from the response

    “• Since October 2025, SCFT staff have access to shared care records via the Plexus system (which links digital care records across Sussex GP’s, hospital and community healthcare services as well as local authorities), enabling real-time access to GP medication summaries and reducing reliance on emailed or static information.”

    Source location

    Response from Sussex Community NHS Foundation Trust
    Page 3 · response
    Published 26 March 2026

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    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

    Embed pharmacy support within the UCR and General Virtual Ward model for complex or unclear medication regimes.

    Verbatim wording from the response

    “• Pharmacy support is now embedded within the UCR/General Virtual Ward model, providing timely expert advice where medication regimes are complex or unclear.”

    Source location

    Response from Sussex Community NHS Foundation Trust
    Page 3 · response
    Published 26 March 2026

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    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

    Revise and implement UCR referral documentation to require receiving agencies to reconcile medicines with prescribers and pharmacies and clarify that UCR MAR charts are for SCFT staff only.

    Verbatim wording from the response

    “• UCR referral documentation is being revised to clearly reinforce current agreements that receiving care agencies must undertake their own medicines reconciliation directly with the prescriber and community pharmacy.”

    Source location

    Response from Sussex Community NHS Foundation Trust
    Page 3 · response
    Published 26 March 2026

    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

    Strengthen referral-pathway expectations that medicines reconciliation is confirmed when care responsibility transfers.

    Verbatim wording from the response

    “• SCFT has strengthened expectations within referral pathways that medicines reconciliation must be confirmed at transitions of care, particularly where responsibility for medicines administration is transferring.”

    Source location

    Response from Sussex Community NHS Foundation Trust
    Page 3 · response
    Published 26 March 2026

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    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

    Photograph all medicines present at assessment and onboarding for every new care package.

    Verbatim wording from the response

    “The following changes have now been implemented:”

    Source location

    Response from Coastal Homecare
    Page 3 · response
    Published 26 March 2026

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    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

    Require staff to cross-check medicines against prescribing records, administration records, and referral documentation during handover.

    Verbatim wording from the response

    “The following changes have now been implemented:”

    Source location

    Response from Coastal Homecare
    Page 3 · response
    Published 26 March 2026

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    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

    Integrate GP Connect into the digital platform and current practice to verify medicines and identify recent changes.

    Verbatim wording from the response

    “• At the time Mr Fisher was receiving support from our service, GP Connect access was not available to our digital platform. Since October 2025, we have fully integrated GP Connect to our digital platform, and into current practice as an additional safeguard to support safer medication management and continuity of care. Subject to appropriate consent arrangements and patient opt-out rights, authorised staff are now able to review GP medication summaries to verify prescribed medicines and identify recent medication changes during referral, assessment, and handover processes. This has strengthened our ability to cross-check medication information and identify discrepancies at an early stage.”

    Source location

    Response from Coastal Homecare
    Page 3 · response
    Published 26 March 2026

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    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

    Receiving care agencies are responsible for medicines reconciliation with prescribers and pharmacies; SCFT MAR charts are not definitive records for external providers.

    Verbatim wording from the response

    “• UCR referral documentation is being revised to clearly reinforce current agreements that receiving care agencies must undertake their own medicines reconciliation directly with the prescriber and community pharmacy.”

    Source location

    Response from Sussex Community NHS Foundation Trust
    Page 3 · response
    Published 26 March 2026

    Open published response

  2. Essex

    AI-generated summary

    Fiona May Humberstone · 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

    Fiona May Humberstone, who had longstanding mental health conditions, alcohol misuse and chronic pain, died at home from an inadvertent overdose of prescribed Oromorph taken with other medication. The concerns included mental health clinicians relying solely on patients’ accounts of their medication and inadequate access to accurate, up-to-date prescribing information between primary and secondary care.

    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

    Reliance on patients’ accounts of current medication without routine verification

    Wider context from the report

    “(1) In her statement provided for the purposes of the inquest, FH’s consultant psychiatrist listed the medications prescribed to FH at the time of her death but made no reference to the Oromorph. During the course of her oral evidence she confirmed that, at the time of her last review of FH in April 2020, she was entirely unaware that she had been prescribed this powerful morphine-based pain killer for a number of months. She also confirmed that had she known of the prescription for that medication it would have affected her risk assessment, given LH’s continuing misuse of alcohol. She told the court that it was (and remains) her usual practice to rely entirely on the information regarding medication (including dosage and frequency) provided by the patient, even in telephone only consultations. She stated that she would only rarely (and certainly not routinely) check the accuracy of the account provided by obtaining a list of medication from the GP or other clinical records. Although not causative in respect of FH’s death, I am concerned that the practice of relying entirely on a patient’s account of current medication, in circumstances where significant mental health issues are often involved (including where there is chronic substance and/or alcohol misuse) gives rise to a serious risk of future deaths. As was accepted by the witness, any risk assessments, care plan reviews or further prescribing of (or alteration to) a medication regimen may in such circumstances be predicated upon incomplete, inaccurate and potentially dangerously misleading information. In my view the risk of future deaths is clear. ”

    Source location

    Fiona May Humberstone · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester North

    AI-generated summary

    Bruce Lee Houghton · 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

    Bruce Lee Houghton died at home on 16 April 2020 from combined drug toxicity, with excess paracetamol likely causing liver damage and accumulation of his other medications. The report states that he had not had his annual medication review, and that these reviews did not ask patients about over-the-counter medicines they purchased in addition to prescribed 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 ask patients about over-the-counter medication during medication reviews

    Wider context from the report

    “2. The Court heard the deceased had not had his annual medication review. The court heard evidence that at these reviews the patients are not asked about any over the counter medication they may purchase in addition to their prescribed medication. ”

    Source location

    Bruce Lee Houghton · 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

    Create a standardised medication-review questionnaire prompting enquiries about over-the-counter medicines and supplements at prescribing and annual reviews.

    Verbatim wording from the response

    “6. The Practice is in the process of creating a standardised medication review template based on good medical practice which will include a prompt to routinely trigger an enquiry as to if the patient is taking any over the counter medication, or supplements at the point of prescribing and at annual reviews. The clinical staff at the practice will all be made aware that they are to complete this questionnaire when prescribing new medication to a patient or when they are conducting a medication review.”

    Source location

    2021-0160-Response-from-Uplands-Medical-Practice_Published
    Page 2 · response
    Published 24 May 2021

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    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

    Share the medication-review questionnaire with partner practices and Manchester Health and Social Care Partnership for feedback and good-practice dissemination.

    Verbatim wording from the response

    “7. This questionnaire will be shared with the 3 other GP practices that are involved in the multidisciplinary team and will also be shared with Manchester Health and Social care Partnership for their views to see if it can be improved in any way and to promote good practice. I have already liaised with Manchester Health and Social Care Partnership to ask for their support and ████████, Senior Primary care Manager for Quality Improvement across Greater Manchester has informed me she will investigate how they can assist. Once this feedback has been received the Practice will look to embed the questionnaire within the current clinical system (Vision) although due to its limitations this may not be possible until the Practice moves to a new clinical system.”

    Source location

    2021-0160-Response-from-Uplands-Medical-Practice_Published
    Page 2 · response
    Published 24 May 2021

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    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

    Recruit three additional permanent salaried GPs.

    Verbatim wording from the response

    “10. The medication review questionnaire and when it should be used will be included in the Practice’s prescribing policy and in-house Practice training on conducting a good medication review will be set up which I will lead. I will be assisted by the Practice manager. The first training on this will occur once the new GPs are in post. The training will also be provided for all new staff as part of their induction, and they will be asked to review the Practice’s prescribing policy. The practice aims to share this fully for feedback at the next practice meeting in August 2021 (17th August 2021) with a view to implementing it thereafter.”

    Source location

    2021-0160-Response-from-Uplands-Medical-Practice_Published
    Page 2 · response
    Published 24 May 2021

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    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

    Employ a permanent pharmacist with medication-review competency and responsibility for improving the prescribing policy and questionnaire.

    Verbatim wording from the response

    “11. The Practice has employed a permanent pharmacist who is set to join in October 2021, after a thorough competency-based interview which specifically included questions about competency in conducting medication reviews and if they were routinely enquiring about over the counter medications as part of these. This was important to the Practice to ensure the pharmacist understands the goals of the Practice. The permanent pharmacist will then have an influence on the prescribing policy and the medication”

    Source location

    2021-0160-Response-from-Uplands-Medical-Practice_Published
    Page 2 · response
    Published 24 May 2021

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    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

    Engage Royal College of General Practitioners practice-development support to review Practice processes and planned safety measures.

    Verbatim wording from the response

    “15. The Practice is engaging the practice development support of the Royal College of GPs to review the Practice processes currently in place and the plans shared above, for feedback and review. I would be happy to provide a further update to the coroner regarding the progress in November 2021 if that is acceptable.”

    Source location

    2021-0160-Response-from-Uplands-Medical-Practice_Published
    Page 3 · response
    Published 24 May 2021

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    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

    The questionnaire may not be embeddable in the current clinical system because of its limitations, until the Practice moves to a new system.

    Verbatim wording from the response

    “7. This questionnaire will be shared with the 3 other GP practices that are involved in the multidisciplinary team and will also be shared with Manchester Health and Social care Partnership for their views to see if it can be improved in any way and to promote good practice. I have already liaised with Manchester Health and Social Care Partnership to ask for their support and ████████, Senior Primary care Manager for Quality Improvement across Greater Manchester has informed me she will investigate how they can assist. Once this feedback has been received the Practice will look to embed the questionnaire within the current clinical system (Vision) although due to its limitations this may not be possible until the Practice moves to a new clinical system.”

    Source location

    2021-0160-Response-from-Uplands-Medical-Practice_Published
    Page 2 · response
    Published 24 May 2021

    Open published response

  4. Inner North London

    AI-generated summary

    Nasar AHMED · 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

    Nasar died following an anaphylactic reaction contributed to by asthma while he was in the internal exclusion room at school. The concerns included delayed or inappropriate advice about using his adrenaline auto-injector, discrepancies and gaps in asthma and allergy care planning, unsuitable emergency inhaler equipment, inadequate medication review systems, and shortcomings in staff awareness, training and emergency procedures.

    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 verify school medication directly during medication reviews

    Wider context from the report

    “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”

    Source location

    Nasar AHMED · Prevention of Future Deaths report
    Page 15 · 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

    Remind staff that medication must be physically present for reviews and treat comparable breaches as gross misconduct with professional referral.

    Verbatim wording from the response

    “We have reminded all of our staff that there are no circumstances when a school nurse would not be expected to have the medication in front of them when conducting a review. Our staff have been reminded that we would consider a similar breach to be an act of gross misconduct and would also result in a professional conduct referral.”

    Source location

    Response from Compass Wellbeing
    Page 2 · response
    Published 3 May 2023

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    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

    Introduce and scan a medication-review checklist into each child’s health record, with completion checked through biannual IHCP audits.

    Verbatim wording from the response

    “To assist with ensuring that medication is visually inspected by school nurses across the service at review meetings, a checklist has also been introduced for use during Individual Health Care Plan (“IHCP”) review meetings. This new measure is designed to ensure that all areas of the review process have been covered during the meeting. This new checklist will act as guidance and prompt to all school nurses and, once completed, will be scanned onto the Child’s Health Record. A copy of the ‘School annual review asthma/wheeze checklist’ is enclosed. The completion of this checklist will form part of the bi-annual IHCP audit, further details of which are provided later in this response.”

    Source location

    Response from Compass Wellbeing
    Page 2 · response
    Published 3 May 2023

    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 all pupil Individual Health Care Plans and verify that emergency-box medicines are prescribed and in date.

    Verbatim wording from the response

    “The Coroner also raised concerns that the system in place for ensuring that actions arising from individual health plans (‘IHP’) and medication reviews were undertaken was not sufficiently robust. Since Nasar’s death, the school’s Safeguarding Committee has undertaken a thorough review of all IHPs for pupils in the school. This included ensuring that all medicines kept within emergency boxes at the school are as prescribed and in date.”

    Source location

    Response from Bow School
    Page 2 · response
    Published 3 May 2023

    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

    Use Safeguarding Committee governance, scheduling, spot checks and compliance reporting to monitor Individual Health Care Plans and medicines.

    Verbatim wording from the response

    “The Safeguarding Committee⁵ has developed a flowchart to outline the responsibilities under the ‘Support students with medical needs’ policy. The committee has an agenda item ‘IHP and medication reviews’ so that effectiveness of managing medical needs is considered at each meeting. It is responsible for setting the schedule of meetings for all IHP or medication reviews on a half termly basis. The school administrator is required to liaise with Compass Wellbeing and the YLM to ensure all parties are present at meetings. The Designated Safeguarding Lead (‘DSL’) also receives details of IHP meetings and the decisions made and conducts spot checks on the IHPs and medicines so that compliance with expectations can be maintained. The DSL provides a compliance report each half term to the safeguarding committee.”

    Source location

    Response from Bow School
    Page 2 · response
    Published 3 May 2023

    Open published response

  5. London (East)

    AI-generated summary

    Mr Harold Goulding · 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 Harold Goulding suffered two falls at a care home on 5 and 6 November 2015, followed by a subdural haematoma, seizure and cardiac arrest; he died on 10 November 2015. The concerns included communication failures between the anticoagulation clinic, GP and care home, and the GP not checking the care home’s medication administration record, meaning he was unaware that Mr Goulding was receiving warfarin.

    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 of General Practitioners to review and approve care home residents’ Medication Administration Records

    Wider context from the report

    “1. The evidence revealed a breakdown of communication between the anti-coagulation clinic, the General Practitioner and the Care Home. The Care Home had registered Mr Goulding with a new General Practitioner but did not notify the anti-coagulation clinic of the details of the new General Practitioner. The community pharmacist therefore continued to provide reports to the old GP. 2. The General Practitioner provided the lead in relation to the administration of medication at the care home. The General Practitioner did not however consider the Medication Administration Record held by the home. The staff providing evidence from the care home agreed that it would reduce risk in the future, if a system is in place to ensure that the General Practitioner attending for new resident reviews, considers and approves the medication set out within the Medication Administration Record. This would not only provide assurance to the Care Home staff in relation to medication that they are administering, but would also ensure that GPs are fully aware of the medication that residents are currently receiving. It was further agreed that in order to reduce future risk, the Care Home staff should take the lead in ensuring that any other health agencies providing care to new residents are informed when the home registers new residents with a new General Practitioner, so that information can be correctly shared. ”

    Source location

    Mr Harold Goulding · 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

    Have the duty nurse accompany GPs on rounds and review medication administration charts and care plans to share relevant information.

    Verbatim wording from the response

    “When the GP visits the Home to attend to the resident’s needs, the Nurse on duty will accompany the GP on his rounds and go through the medication administration charts and care plans to ensure all information is shared where necessary. A handover document for use with new resident’s details has been created to ensure relevant information is shared with the new GP where required.”

    Source location

    2016-0248-Response-by-Orchard-Care-Homes
    Page 2 · response
    Published 14 July 2016

    Open published response

  6. West Sussex

    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

    Failure to complete medication reconciliation on admission and pre-assessment

    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 3 · 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