Recurring concern

Unreliable assessment of medication concordance in mental health care

First to latest report 28 Jun 2021 — 17 Feb 2025

Reports that mention this concern
3
Times this concern has been raised
5
Stated actions linked to this concern
1

What this concern includes

Includes failures of the mental-health process for assessing medication concordance, including obtaining and reviewing medication history, prescriptions and reported medication use, distinguishing ineffective treatment or alternative use from misuse, and incorporating concordance findings into clinical review and decision-making.

What is not included
  • Excludes general medication prescribing, administration, supply, monitoring or reconciliation failures unless the asserted deficiency specifically concerns assessment of medication concordance.
  • Excludes generic access-to-records or clinical-review delays unless they directly impair assessment of medication concordance in mental health care.
  • Excludes failures to engage or follow up patients where medication concordance assessment is not the shared unsafe condition.
  • Excludes generic mental-health risk assessment or care-planning failures without a material medication-concordance assessment component.

Reports and published responses 3 reports

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

  1. Essex

    AI-generated summary

    DAVID WAYNE BENNETT · 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 Wayne Bennett died by hanging on 13 June 2023 after being found suspended by a ligature, with cocaine and alcohol ingestion. He had a history of drug-induced psychosis and had sought help for deteriorating mental health, psychosis and lack of sleep before his death. Concerns included inadequate sharing and recording of mental-health and primary-care information, unclear urgent-care pathways, failures to escalate requests for urgent medication review, and insufficient mental-health assessment and liaison at hospital.

    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 identify and escalate unrequested antipsychotic medication

    Wider context from the report

    “(5) Mr Bennett had an open prescription for antipsychotic medication on his GP record that was not being requested and the primary care mental health nurse did not ask about this and the nurse did not inform the GP or seek any advice from her line manager who was a nurse prescriber. ”

    Source location

    DAVID WAYNE BENNETT · 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

    Train Mental Health Practitioners to locate current and historical prescriptions in SystmOne.

    Verbatim wording from the response

    “Response: Current and historic prescriptions can be viewed on SystmOne by practitioners based within a GP practice, hence prescriptions / history are available to view as required by attending practitioners. Planned training for Basildon and Brentwood MHP’s will ensure all MHP’s are aware of where to allocate current and historical prescriptions in SystmOne. In addition the team is working with the local private provider on exploring if there are additional modules available on Systmone which will further support care delivery pathways.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 18 February 2025

    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

    Concerns about care before 6 June 2023 do not relate to the respondent, so it has identified no action concerning them.

    Verbatim wording from the response

    “I understand from my colleagues in attendance at the Inquest hearing, that these matters of concern; points 1 – 5, do not relate to Mid and South Essex NHS Foundation Trust (MSEFT), and we have not identified any action to be taken in respect of these.”

    Source location

    Response from Mid & South Essex NHS Trust
    Page 2 · response
    Published 18 February 2025

    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

    The Line Manager would not have prescribed medication because prescribing for this case was outside the manager’s remit.

    Verbatim wording from the response

    “As set out in evidence, the MHP ought to have discussed this case with a Nurse Prescriber or the Line Manager, the request for medication could have been looked into further. Whilst this would provide insight into medication history, the Line Manager has confirmed that he would not have prescribed any medication for Mr Bennett in light of the fact this is out of his remit. Mr Bennett’s case would have been presented at the First Response Team’s (FRT)”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 2 · response
    Published 18 February 2025

    Open published response

  2. Suffolk

    AI-generated summary

    Amy Jade BUTCHER · 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

    Amy Jade Butcher was declared deceased on 14 May 2023 after suspending herself with a ligature around her neck during a heightened anxiety crisis. The inquest identified concerns about a confusing, fragmented system for prescribing mental health medication, and about the decision not to prescribe Lorazepam despite its previous effectiveness for Amy.

    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 make an appropriate medication-concordance assessment when patients use alternative medication because PRN medication is ineffective

    Wider context from the report

    “Evidence was heard that a decision had been made by the Mental Health Multi-Disciplinary Team that Lorazepam was not to be prescribed to Amy in any event. The court heard that Lorazepam was highly addictive and the subject of frequent misuse by individuals to whom it was prescribed. There were two reasons given for the MDT decision. Firstly, Amy had volunteered to the Mental Health Team, that she had previously purchased online a ‘micro dose of hallucinogenic mushrooms’ to try and alleviate her systems. The court heard that like ‘homeopathic medication’ only a tiny amount of the active hallucinogen found in mushrooms would have been present, but that it was still illegal to possess this in the UK. Amy had told the team that she had only used this once. The MDT decision was that because this was an illegal drug, because the MDT were unaware that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and because they did not know how it would react with the Lorazepam, no Lorazepam was to be prescribed to Amy. Secondly, Amy had previously disposed of medications prescribed to her which made her feel worse (a known side effect of some medications in the first few days of taking them). When advised to restart them, repeat prescriptions had to be made. In addition, just prior to her death Amy volunteered that she had been taking a sleeping tablet (Zopiclone) in the mornings, as well as taking them when she was supposed to at night. Amy had said that her current PRN medication had no effect, but the Zopiclone did help. As a result, it was recorded by the MDT that Amy was ‘non-concordant’ with her medication regime, therefore making her a higher risk of prescription misuse. However, in her evidence, the Emergency Department Consultant said she was fully aware of the fact that micro dosing of hallucinogenic mushrooms was being used by mental health patients, and that due to the tiny amount of active hallucinogen it was generally not a barrier to the prescription of any other medication. In addition, the Emergency Department Consultant stated that if an individual had ingested a toxic quantity of hallucinogenic mushrooms, there was no contra-indication for the prescription of Lorazepam as it was often prescribed to reduce the hallucinogenic effects. In the evidence heard from members of the MDT, it was clear that the illegal use of a ‘micro dose of hallucinogenic mushrooms’ coupled with Amy’s non-concordance, led to the decision not to prescribe her Lorazepam. As such, a lack of knowledge in relation to the common usage of micro dose hallucinogenic mushrooms as a self-treatment by mental health patients, a lack of knowledge in relation to there being no contra-indications for prescription of Lorazepam if micro dose hallucinogenic mushrooms were being used, and defining Amy as ‘non-concordant’ due to her use of Zopiclone when her PRN medication proved ineffective, prevented a realistic opportunity for the MDT to consider if Lorazepam should have been prescribed to Amy. ”

    Source location

    Amy Jade BUTCHER · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  3. 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

    Failure of primary and secondary care systems to provide timely access to definitive medication and concordance records

    Wider context from the report

    “(2) Further, oral evidence from a senior EPUT witness confirmed that the Trust could not, as electronic systems were presently configured, readily access information held by GP practices regarding individual patients (and vice versa). It appeared that this evidence was provided by way of an explanation as to why accurate and up to date medication/prescribing information was not routinely obtained by clinicians in advance of reviews of patients. Absent any other system for ensuring swift and accurate information transfer between primary and secondary care providers, then the continuation of a state of affairs where a consultant psychiatrist is undertaking a review of a mental health patient but does not have access to a definitive record of the medication presently being taken by that patient (and/or their concordance with prescribed medication) gives rise to a conspicuous risk of future deaths. The EPUT witness suggested that this was a matter for the Clinical Commissioning Group (CCG) to address. ”

    Source location

    Fiona May Humberstone · 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

    Insufficient time for responsible clinicians to consider medical records before mental health reviews

    Wider context from the report

    “(3) Issues regarding the necessity for access to (and adequate time for the consideration of) medical records including prescriptions and concordance with medication in advance of mental health reviews undertaken by responsible clinicians has been raised in relation to mental health related death in Essex previously. I am concerned that the evidence from FH’s inquest indicates that such matters remain unresolved. ”

    Source location

    Fiona May Humberstone · Prevention of Future Deaths report
    Page 3 · 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

    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

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