Recurring concern

Unreliable safeguarding response to medication maladministration

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First reported 8 Oct 2015•Latest report 12 Nov 2025

Definition

What this concern includes

Includes failures in the dedicated safeguarding response to medication maladministration, including recognition of safeguarding risk, appropriate classification, referral, investigation, escalation and follow-up of suspected or reported maladministration of medication.

Not included

Excludes ordinary medication prescribing, dispensing, administration or monitoring failures where no concern about maladministration and its safeguarding response is identified.
Excludes generic safeguarding, incident-reporting or investigation deficiencies that are not specifically connected to medication maladministration.
Excludes theft or property-crime handling where medication maladministration is not the material safety concern.
Excludes failures to implement safety actions after a medication-maladministration investigation has been completed, unless the response process itself was also deficient.

Reports: 3
Individual concerns: 5
Date range: 2015–2025
Stated actions: 2

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1

Royal Bolton Hospital1

St George'S University Hospitals 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.

12 Nov2025
Inner West London
Concerns raised1
1. Lack of investigation of medication maladministration concerns
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review reported incidents, provide feedback, and operate PSIRF-based divisional incident review and escalation processes.
  Stated by St George’s, Epsom and St Helier University Hospitals and Health GroupStated completed
AI-generated summary

Mr Barry Clive Loxston · 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 Barry Clive Loxston died at St George’s Hospital on 30 July 2023 after complications following renal transplant surgery, including electrolyte imbalance and delayed graft function. The report identifies concerns about failures to recognise his unfitness for surgery, inadequate patient handling, unsupervised medication administration, insufficient investigation, incomplete review of blood tests, and gaps in systems for assessing transplant-list suitability and communication between nephrology teams.

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 investigation of medication maladministration concerns
Wider context from the report
“3. That lack of investigation of the matter outlined in 2 increases the risk to patients of the concern outlined in 2. ”
Source location
Mr Barry Clive Loxston · Prevention of Future Deaths report
Page 3 · 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
Review reported incidents, provide feedback, and operate PSIRF-based divisional incident review and escalation processes.

Verbatim wording from the response
“Matter 3: It is acknowledged that there was a lack of investigation and a lack of process in the management of medication safety incidents across the directorate. It is also acknowledged that there was a culture of under reporting incidents and, therefore, investigations that should have taken place did not. Since March 2024 the care group has seen a rise in incident reporting, especially near miss incidents. This is believed to be due to the changes in culture and education; incident reporting is widely welcomed by the senior team and all incidents are reviewed and fed back to the reporter.”

Source location
Response from St George's University Hospitals
Page 3 · response
Published 14 November 2025
Open published response
28 Dec2018
Manchester South
Concerns raised3
1. Failure of GMP call handlers to recognise safeguarding risks in opioid maladministration reports
2. Failure of local division assessors to recognise safeguarding risks in opioid maladministration reports
3. Failure of the CDLO to liaise with the local police unit and discuss safeguarding implications
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Implement the Controlled Drugs Regulations establishing tighter controls and mandatory governance arrangements for prescribing, records, custody, monitoring and accountable officers.
  Stated by Department of Health and Social CareStated completed
Respondent positions 1
1. Position
  Concerns about police responses and national learning should be raised with the Home Secretary because Controlled Drug Liaison Officers are police employees.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Joan Wright · 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

Joan Wright, who had poor mobility and was unable to communicate verbally, died at Belmont Residential Home on 16 September 2017; the post-mortem found extensive coronary artery atheroma. The report raised concerns about the incorrect administration and handling of Oramorph, medication management at a care home rated inadequate, and failures to recognise and address safeguarding risks after the medication incident.

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 GMP call handlers to recognise safeguarding risks in opioid maladministration reports
Wider context from the report
“4. GMP’s call handler did not recognise the potential safeguarding risks of the maladministration of opioids to a vulnerable member of the community and referred the report to the local division. The local division assessor (LRO) failed to recognise the safeguarding risks and filed the report as theft. GMP have changed their policies significantly since the matter was referred to them after Mrs Wright’s death. However it was unclear about whether or not the issue had been addressed by Forces nationally. The inquest was told that the CDLO role had been brought in after the Shipman inquiry to ensure safeguarding risks were identified in relation to maladministration of drugs; ”
Source location
Joan Wright · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of local division assessors to recognise safeguarding risks in opioid maladministration reports
Wider context from the report
“4. GMP’s call handler did not recognise the potential safeguarding risks of the maladministration of opioids to a vulnerable member of the community and referred the report to the local division. The local division assessor (LRO) failed to recognise the safeguarding risks and filed the report as theft. GMP have changed their policies significantly since the matter was referred to them after Mrs Wright’s death. However it was unclear about whether or not the issue had been addressed by Forces nationally. The inquest was told that the CDLO role had been brought in after the Shipman inquiry to ensure safeguarding risks were identified in relation to maladministration of drugs; ”
Source location
Joan Wright · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of the CDLO to liaise with the local police unit and discuss safeguarding implications
Wider context from the report
“3. Following the maladministration of medication to Mrs Wright, the inquest heard that the matter was reported to GMP .The CDLO investigated but did not liaise with the local police unit or discuss the safeguarding implications; ”
Source location
Joan Wright · 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
Implement the Controlled Drugs Regulations establishing tighter controls and mandatory governance arrangements for prescribing, records, custody, monitoring and accountable officers.

Verbatim wording from the response
“You mention the Shipman Inquiry in your report. In response to the Shipman Inquiry's Fourth Report¹, there have been significant changes in the governance arrangements for the use and management of controlled drugs.”

Source location
2018-0408-Response-by-Department-of-Health
Page 1 · response
Published 28 December 2018
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 police responses and national learning should be raised with the Home Secretary because Controlled Drug Liaison Officers are police employees.

Verbatim wording from the response
“Your report raises concerns about the actions of Greater Manchester Police in responding to the potential safeguarding risks following the incident report of maladministration of Oramorph to Mrs Wright, and questions if learning from this incident has been shared at a national level.”

Source location
2018-0408-Response-by-Department-of-Health
Page 5 · response
Published 28 December 2018
Open published response
8 Oct2015
Manchester West
Concerns raised1
1. Failure to investigate concerns about excess medication doses
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Maureen Chatterley · 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

Maureen Chatterley died at Royal Bolton Hospital on 24 December 2014 after a fall causing a right hip fracture, subsequent dislocations and multiple surgical procedures. The report raised concerns that a possible excess dose of lorazepam was not investigated and that medication stock in patient drawers and ward cupboards was not recorded or controlled, although the Inquest accepted that any excess dose did not contribute to her death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to investigate concerns about excess medication doses
Wider context from the report
“1. During the Inquest evidence was heard that i. There was no investigation by the hospital in relation to the concerns expressed by the family in relation to the administration of an excess dose of Lorazepam. ii. There was no record of the stock of medication in relation to non-controlled drugs in the medication drawer allocated to a patient nor in and the medication cupboard on the ward. Accordingly medication could be removed from the medication cupboard on the ward and used either for an elicit purpose or excess dosage without any knowledge or record with reference to stock control. Evidence was given at the Inquest that the pharmacist checked medications on the ward on a daily basis but there was no check or record of the number of medications or the number of tablets in the allocated medication drawers or the cupboard on ward, particularly between the daily inspections by the pharmacist. ”
Source location
Maureen Chatterley · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of investigation of medication maladministration concerns

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

Concerns raised3

Failure of GMP call handlers to recognise safeguarding risks in opioid maladministration reports

Failure of local division assessors to recognise safeguarding risks in opioid maladministration reports

Failure of the CDLO to liaise with the local police unit and discuss safeguarding implications

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to investigate concerns about excess medication doses

Actions described in response 1

Actions described in response 1

Respondent positions 1