Recurring concern

Unreliable medication reconciliation across care transitions

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First reported 13 Dec 2008•Latest report 19 Mar 2026

Definition

What this concern includes

Includes failures dedicated to reconciling, verifying, correlating, transferring or maintaining a patient’s medication information across clinical records or transitions of care, including medication lists, problem lists, admission or discharge records, community-to-hospital records and medication administration documentation.

Not included

  • Excludes generic failures in documentation, communication, staffing or clinical review that are not specifically tied to medication reconciliation.
  • Excludes medication prescribing or administration errors unrelated to an information-reconciliation failure.
  • Excludes reconciliation of non-medication items, such as property, race participants or general patient accounts.
  • Excludes failures concerning a different named safety system or hazard unless the report directly identifies medication reconciliation as the unsafe process.
Reports
18

Distinct published reports

Individual concerns
20

A report can raise multiple concerns

Date range
2008–2026

First to latest report issue date

Stated actions
39

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England3
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Bow School1
Bristol NHS Foundation Trust1
Bromley by Bow Health Centre1
Cardiff & Vale University LHB1
Care Quality Commission1
Carewatch (Mid Bucks)1
Chesterfield Royal Hospital NHS Foundation Trust1
Coastal Homecare – Hove Branch1
Compass Wellbeing Tower Hamlets1
Department of Health and Social Care1
Good Hope Hospital1
Greater Manchester Mental Health NHS Foundation Trust1

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.

  1. Surrey

    AI-generated summary

    Margaret Jean Silver · 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

    Margaret Jean Silver, an 85-year-old resident of a care home, developed pulmonary emboli after Rivaroxaban was discontinued following contradictory medication instructions in her hospital discharge summary. She later experienced reduced mobility, sustained a fractured femur in an assisted fall, developed a chest infection, and died in hospital. Concerns included contradictory discharge medication information, failure to identify that Rivaroxaban had been discontinued, and failures in communicating and implementing recommended discharge support and equipment.

    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 hospital admission and discharge medication-recording procedures to identify non-receipt of potentially life-saving medication

    Wider context from the report

    “- The procedures in place for recording a patient’s medication on admission to, and discharge from, hospital may fail to identify circumstances in which a patient is no longer in receipt of potentially life-saving medication. ”

    Source location

    Margaret Jean Silver · Prevention of Future Deaths report
    Page 4 · 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

    Introduce electronic prescribing to improve medicines communication, decision support, administration, supply and auditability.

    Verbatim wording from the response

    “The Trust intends to introduce electronic prescribing in 2019. This system utilises electronic systems to facilitate and enhance the communication of a prescription or medicine order, aiding the choice, administration and supply of a medicine through knowledge and decision support and providing a robust audit trail for the entire medicines use process.”

    Source location

    2018-0002-Response-by-Ashford-and-St-Peters-Hospitals-NHS-Trust
    Page 1 · response
    Published 7 March 2018

    Open published response

  2. 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 confirm replacement medication and complete its dose in the action plan

    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

    Deliver tailored biannual school-nursing training covering record keeping, communication, action follow-up, electronic diaries and diary management.

    Verbatim wording from the response

    “In addition to the above training, the bi-annual training received by the school nursing service was delivered in June 2017. During bi-annual training, the service is suspended and training takes place across all staff groups. The training has been tailored to support the key learning points from the tragic death of Nasar Ahmed and the requirements and expectations of a school nurse. It covered a range of key areas including how to improve record keeping and the importance of this, the increased function of school nurse administrators in communication and following up of actions with key staff in school and the parents, the use of electronic diary systems and diary management. A copy of the training schedule undertaken in June 2017 is attached.”

    Source location

    Response from Compass Wellbeing
    Page 4 · 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

    Implement measures requiring school nurses to follow up and update IHCP meeting actions routinely.

    Verbatim wording from the response

    “CWB have implemented additional measures to ensure that the checking and updating of actions from IHCP meetings are routinely followed up by all school nurses and to prevent this event from happening again.”

    Source location

    Response from Compass Wellbeing
    Page 7 · 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

    Train clinical staff to use electronic diaries, reminders, shared calendars and mobile devices for appointment and action follow-up.

    Verbatim wording from the response

    “All clinical staff have received guidance on how to manage an electronic diary in order to assist staff in diarising appointment, reminders and sharing calendar appointments. All clinical staff have access to mobile working devices, for example laptops, and the service is moving to a fully electronic diarising system in order to support sharing of appointment calendars and the effective use of an electronic diary and reminder system. Specific training on electronic diarising and the use of this took place on 21 June”

    Source location

    Response from Compass Wellbeing
    Page 7 · 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

    Implement monitored procedures for arranging and following up Individual Health Care Plan and medication reviews, including senior oversight and deadline reminders.

    Verbatim wording from the response

    “The Executive Headteacher, along with Headteacher representatives from across the area, has been invited by the Local authority to meet to discuss the school nursing service as part of a scheduled contract renewal process. This meeting is due to take place later this year, but it is understood that the concerns identified during the Inquest will inform that process. In the interim the school has been working with Compass Wellbeing to clarify the procedure for setting up IHP meetings and medication reviews. The school has had additional processes to ensure this procedure is robustly monitored at senior level. The procedure requires that, in all cases an update of the pupil’s medical need is required at each review.”

    Source location

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

    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

    Checking that in-date medication is provided is a shared responsibility between the school and school nurse.

    Verbatim wording from the response

    “The Supporting Medical Needs Policy indicates that the responsibility of checking that in-date medication is provided is a shared one between the school itself and the school nurse. It is fully expected that the school nurse and the school would have a conversation to discuss follow-up actions arising from a meeting and appropriately diarise to check that the correct medication has been received and, if not received, to chase this up in a timely manner. As a qualified health professional, the school nurse is able and expected to understand whether a prescription is appropriate and whether the correct medication has been received. Any outstanding actions must be followed up and completed as a matter of course and in accordance with their professional duties.”

    Source location

    Response from Compass Wellbeing
    Page 7 · response
    Published 3 May 2023

    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

    Parents or the school nurse are principally responsible for contacting the pupil’s GP or other treating medical professionals before reviews.

    Verbatim wording from the response

    “Principally it remains the responsibility of the child’s parents or school nurse to make contact with the child’s GP or other medical professionals involved in their care prior to the meeting. Where, at the review meeting, this hasn’t been done or there is any uncertainty regarding the pupil’s current need the school nurse is required to follow up with direct contact to the pupil’s GP and confirm the position to the school administrator by email. The deputy head responsible for safeguarding is also copied into those emails. The procedure also differentiates between medication reviews and IHP meetings/reviews to ensure that necessary follow up can be scheduled separately. For example, where actions are required as a result of the medication review, a follow up review is scheduled for the following week.”

    Source location

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

    Open published response

  3. Manchester South

    AI-generated summary

    Rachel Morgan · 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

    Rachel Morgan, who had post-natal depression with psychotic symptoms and was considered at high risk of suicide, was found with a ligature around her neck on 16 April 2016 and died from severe anoxic brain injury on 24 April 2016. The principal concerns were delays in reviewing her medication, failures to update risk assessments after information about her suicide risk was received, insufficient observation levels, and a lack of clarity about observation 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 complete medication summaries during admission clerking

    Wider context from the report

    “(1) I am concerned that despite the fact that Rachel Morgan and her family made it clear to the staff at the Medlock Ward from the start of her admission that she wanted her medication to be reviewed as felt that her anti-depressant medication was not working, no steps were taken to begin the review process during the 4 days she was an inpatient before her death. I am concerned that in the knowledge that Rachel was reporting issues with her medication, a medication summary could have been undertaken before the first ward round took place on the 15th April. Please consider whether on admission patients should have a medication summary completed as part of the clerking process, which would allow any medication reviews to be conducted by an appropriate Doctor at the first available opportunity. ”

    Source location

    Rachel Morgan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Cardiff and the Vale of Glamorgan

    AI-generated summary

    Kathleen Ludmila Neville · 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 Ludmila Neville was admitted to hospital after an accidental fall that fractured her femur and later died following complications after surgery and a prolonged hospital stay. Her regular thyroid medication was omitted for five weeks because it was not recorded on the drug chart and the hospital lacked a Medication Reconciliation Policy; this contributed to lassitude and confusion but not to her death. The principal concern was that the absence of such a policy could allow medication errors to persist and potentially contribute to future deaths, particularly with medicines whose omission could be fatal.

    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

    Absence of a medication reconciliation policy at the University Hospital of Wales

    Wider context from the report

    “(1) The absence of a Medication Reconciliation Policy at the University Hospital of Wales over the relevant period made it much harder for the individual failures of the admitting doctor and initial pharmacist to be picked up. As a consequence Kathleen Neville was deprived of her medication for a much longer period than would otherwise have been the case. (2) While the Coroner found in this inquest that the omission of Levothyroxine did not contribute to the eventual outcome, the position would have been far different in the case of other drugs where omission of medication might lead directly to death (e.g. in insulin). In such cases the absence of a Medication Reconciliation Policy assist in picking up individual failures could lead to future deaths. The Coroner found that any system that relies solely on individual human excellence without a supporting policy is eventually bound to fail through individual human error. ”

    Source location

    Kathleen Ludmila Neville · 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

    Lack of medication reconciliation policies at other Health Boards across Wales

    Wider context from the report

    “(4) The Coroner is concerned that there may be other Health Boards across Wales that have still not adopted a Medication Reconciliation Policy as recommended by NICE. Future lives may be lost if a Health Board does not have such a policy and similar prescription errors are made. The Coroner is concerned that all Health Boards across Wales should learn the lessons of this inquest and have a Medication Reconciliation Policy in place to prevent future deaths in similar circumstances. ”

    Source location

    Kathleen Ludmila Neville · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Birmingham and Solihull

    AI-generated summary

    Lottie Reid · 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

    Lottie Reid, aged 95, was readmitted to hospital with haematemesis and melaena and died on 29 January 2015. The inquest concluded that she died from bleeding duodenal ulcers on a background of other significant natural disease, with her death probably accelerated by bleeding exacerbated by anticoagulant therapy. Concerns were raised that the medication administration chart at the intermediate care centre did not mirror the hospital discharge documentation and that there was no clear protocol for checking discrepancies, particularly at weekends.

    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 ensure that the electronic medication administration chart mirrors the discharge medication documentation

    Wider context from the report

    “(1) That following discharge from Good Hope Hospital to Perry Trees Intermediate Care Centre the Printed Electronic Prescribing Medication Adm Chart did not mirror the medication referred to in the Discharge Letter and Prescription. (2) There did not appear to be a protocol in place whereby such discrepancies could be easily checked and this appeared to be especially difficult to do at weekends ”

    Source location

    Lottie Reid · 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

    Amend the nursing discharge checklist to remind staff to check the PEPMAC.

    Verbatim wording from the response

    “In order that the risk of future events can be reduced the following steps have been taken by the Trust:”

    Source location

    2015-0241-Response-by-Birmingham-Heartlands-Hospitals
    Page 2 · response
    Published 25 June 2015

    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

    Improve and standardise yellow-card discharge documentation to provide optimal information for safe prescribing and administration.

    Verbatim wording from the response

    “In addition to strengthening the processes as described above, we consider that this case is an opportunity to improve the discharge process and the documentation in particular:”

    Source location

    2015-0241-Response-by-Birmingham-Heartlands-Hospitals
    Page 2 · response
    Published 25 June 2015

    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

    Obtain governance approval and pilot the revised yellow-card documentation within palliative care.

    Verbatim wording from the response

    “This process will reduce the risk of inconsistency in the discharge documents for the patient, as there will only be one document that the clinicians will refer to on discharge. The template will be standardised to ensure it contains the optimal information for safe prescribing and administration.”

    Source location

    2015-0241-Response-by-Birmingham-Heartlands-Hospitals
    Page 2 · response
    Published 25 June 2015

    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

    Make a final decision on extending the revised discharge documentation process to intermediate-care discharges after piloting and feedback review.

    Verbatim wording from the response

    “Once the new documentation has been approved through our governance processes, it will be piloted within palliative care. Subject to feedback from the community staff, a final decision as to the appropriateness of implementing this process for patients being discharged into an intermediate care facility will be made. It is likely that this decision will be made in the next six months, and will be based on clarity of the prescribing and a review of any reported incidents.”

    Source location

    2015-0241-Response-by-Birmingham-Heartlands-Hospitals
    Page 2 · response
    Published 25 June 2015

    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

    Check available MAC charts and TTOs for medication discrepancies.

    Verbatim wording from the response

    “6. To strengthen the current pharmacy processes, when available, MAC charts and TTOs are checked for discrepancies. As part of our response, the incident was discussed with the pharmacist involved. The Chief Pharmacist has also reminded all of her pharmacists about the importance of this issue. The Chief Pharmacist is also reviewing existing SOPs to ensure they are robust and fit for purpose.”

    Source location

    2015-0241-Response-by-Birmingham-Heartlands-Hospitals
    Page 2 · response
    Published 25 June 2015

    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

    Remind all pharmacists about the importance of identifying medication discrepancies between MAC charts and TTOs.

    Verbatim wording from the response

    “6. To strengthen the current pharmacy processes, when available, MAC charts and TTOs are checked for discrepancies. As part of our response, the incident was discussed with the pharmacist involved. The Chief Pharmacist has also reminded all of her pharmacists about the importance of this issue. The Chief Pharmacist is also reviewing existing SOPs to ensure they are robust and fit for purpose.”

    Source location

    2015-0241-Response-by-Birmingham-Heartlands-Hospitals
    Page 2 · response
    Published 25 June 2015

    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 existing pharmacy SOPs to ensure they are robust and fit for purpose.

    Verbatim wording from the response

    “6. To strengthen the current pharmacy processes, when available, MAC charts and TTOs are checked for discrepancies. As part of our response, the incident was discussed with the pharmacist involved. The Chief Pharmacist has also reminded all of her pharmacists about the importance of this issue. The Chief Pharmacist is also reviewing existing SOPs to ensure they are robust and fit for purpose.”

    Source location

    2015-0241-Response-by-Birmingham-Heartlands-Hospitals
    Page 2 · response
    Published 25 June 2015

    Open published response

  6. Bedfordshire and Luton

    AI-generated summary

    James Duncan STEWART · 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

    James Duncan STEWART, a resident of Manton Heights Nursing Home, was admitted to hospital with decreased mobility and responsiveness after his Parkinson’s medication had apparently not been provided. He was discharged to Airedale Nursing Home for end-of-life care and died on 21 April 2014. The principal concerns were the absence of a system to check medication details with a previous GP practice and uncertainty about responsibility for confirming the correct medication prescription.

    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 medication-detail checks with the previous GP practice when prescribing responsibility changes

    Wider context from the report

    “(1) There did not appear to be any system whereby when a new GP Practice is requested to prescribe medication from a patient’s Nursing Home the details are not checked with the previous Practice. Such a system would have highlighted the fact that Mr. Stewart’s Co-Careldopa medication had not been included. (2) It was felt by those giving evidence from the GP Practice, and from the two Nursing Homes, that the correct medication to be prescribed should be a matter for the General Practitioner to confirm rather than relying upon qualified staff from the Home. They also felt that the Clinical Commissioning Group were the obvious body to ensure that a robust and consistent system is put in place. ”

    Source location

    James Duncan STEWART · 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

    Develop and consult stakeholders on a medication-reconciliation protocol for transfers into care homes and registration with a new GP.

    Verbatim wording from the response

    “In the meantime, in liaison with GP colleagues, Bedfordshire Clinical Commissioning Group have developed a protocol for reconciliation of medications when people are transferred into care homes and are registered with a new GP. The protocol is under consultation with stakeholders in primary and social care. This will also be shared with the commissioners of General Practitioners, NHS England Area Team, for them to consider whether contractual actions can be taken to strengthen compliance with the protocol. An action plan has been written to drive this work forward and progress will be monitored by our Patient Safety and Quality Committee.”

    Source location

    2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
    Page 2 · response
    Published 4 December 2014

    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

    Share the medication-reconciliation protocol with GP commissioners and NHS England’s Area Team for consideration of contractual compliance measures.

    Verbatim wording from the response

    “In the meantime, in liaison with GP colleagues, Bedfordshire Clinical Commissioning Group have developed a protocol for reconciliation of medications when people are transferred into care homes and are registered with a new GP. The protocol is under consultation with stakeholders in primary and social care. This will also be shared with the commissioners of General Practitioners, NHS England Area Team, for them to consider whether contractual actions can be taken to strengthen compliance with the protocol. An action plan has been written to drive this work forward and progress will be monitored by our Patient Safety and Quality Committee.”

    Source location

    2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
    Page 2 · response
    Published 4 December 2014

    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

    Write an action plan to drive the medication-reconciliation work forward and monitor its progress through the Patient Safety and Quality Committee.

    Verbatim wording from the response

    “In the meantime, in liaison with GP colleagues, Bedfordshire Clinical Commissioning Group have developed a protocol for reconciliation of medications when people are transferred into care homes and are registered with a new GP. The protocol is under consultation with stakeholders in primary and social care. This will also be shared with the commissioners of General Practitioners, NHS England Area Team, for them to consider whether contractual actions can be taken to strengthen compliance with the protocol. An action plan has been written to drive this work forward and progress will be monitored by our Patient Safety and Quality Committee.”

    Source location

    2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
    Page 2 · response
    Published 4 December 2014

    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

    Continue local efforts to improve information-technology systems and communication between care providers.

    Verbatim wording from the response

    “Use of Information Technology (IT) solutions is key to standardising practice and improving patient safety particularly in relation to medicines management. Initiatives relating to electronic prescribing in acute and primary care which are in discussion stages but are currently underdeveloped across Health and Social Care and remain a barrier to efficient communication processes. We will continue to endeavour to improve IT systems as far as possible locally to improve communication between care providers.”

    Source location

    2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
    Page 2 · response
    Published 4 December 2014

    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

    National and incompatible IT systems prevent fully standardising electronic medicines information transfer between care providers.

    Verbatim wording from the response

    “(1) There is currently no standardised system for when a GP practice is requested to prescribe medication for a new patient at a nursing home to include checks with the previous practice. Practices have developed local processes to facilitate accurate prescribing, however these remain subject to inconsistencies and interpretation. The main current IT software (called System One) in primary care does not have a process to share an accurate list of prescribed medicines and there is a delay in transfer of records to the new registered GP. This remains a national IT issue further complicated when GP practices are utilising IT systems which are not compatible.”

    Source location

    2014-0526-Response-by-Bedfordshire-Clinical-Commissioning-Group
    Page 1 · response
    Published 4 December 2014

    Open published response

  7. 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

  8. Buckinghamshire

    AI-generated summary

    Heather Beatrice Planner · 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

    Heather Beatrice Planner died at Wycombe Hospital on 1 April 2019 from a gastrointestinal bleed in the context of large bowel ischaemia. The report states that she had not received her prescribed apixaban anticoagulation at home for two days before admission, and identifies concerns about medication administration, communication and record-keeping processes for carers, as well as the subsequent investigation.

    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 cross-checking to prevent carers repeating inherited medication errors

    Wider context from the report

    “(2) It is unclear what additional measures or cross-checking have been introduced to prevent a subsequent carer, who is attending a patient, from inheriting a medication error from an earlier attendance and repeating that error. ”

    Source location

    Heather Beatrice Planner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026