Recurring concern

Unreliable access to clinically required medication during supply shortages

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First reported 13 Oct 2014•Latest report 31 Mar 2025

Definition

What this concern includes

Includes failures in the dedicated medication-shortage response and continuity process, including shortage planning, escalation, communication of roles and alternatives, prioritisation, sourcing and arrangements to prevent patients being left without clinically required medication.

Not included

  • Excludes ordinary medication prescribing, administration, monitoring or counselling failures where no medication supply shortage or shortage-response deficiency is identified.
  • Excludes shortages of non-medication clinical equipment, such as cannulae, unless the assertion explicitly concerns medication supply.
  • Excludes isolated medication stock shortages where no continuing failure in shortage management, communication or continuity of access is identified.
  • Excludes generic information-sharing or leaflet deficiencies that are not tied to maintaining access to clinically required medication during a supply shortage.
Reports
4

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
10

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.

Department of Health and Social Care1
General Pharmaceutical Council1
Midway Pharmacy1
Royal Free Hospital1
Tameside and Glossop Integrated Care NHS Foundation Trust1
University Hospitals of Leicester NHS 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. Inner North London

    AI-generated summary

    Abu RAHMAN · 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

    Abu Rahman, aged 88, suffered a traumatic fall causing a fractured hip and underwent hemi-arthroplasty before deteriorating with pneumonia on a background of end stage renal failure. Concerns included delays in obtaining Naloxone when supplies ran out and limited awareness of opioid toxicity or accumulation in patients with kidney impairment or failure.

    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 timely availability of Naloxone

    Wider context from the report

    “Firstly, I heard evidence from the family that nursing staff were frequently unable to administer Naloxone as it had run out. They had to obtain more Naloxone from the pharmacy, which led to delays for “hours and hours” on multiple occasions. Secondly, I heard evidence concerning a lack of awareness or appreciation concerning the risk of opioid toxicity / accumulation in patients with kidney impairment/failure, even where the “correct” dose may have been given. I am concerned that if there is no proper or properly implemented system for obtaining medication in a timely manner, and limited awareness of the matters canvassed above, then this gives rise to a risk of future deaths. ”

    Source location

    Abu RAHMAN · 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

    Deliver two weeks of safety-huddle sessions on accessing and replenishing Naloxone, including out-of-hours arrangements.

    Verbatim wording from the response

    “Clarity on the process of accessing Naloxone, including out of hours, should stock need replenishing will be shared at daily huddles for two weeks. In addition, pharmacy will be increasing the stock level on 8 North ward to reduce the likelihood of it not being immediately available. Stock levels have been increased from 2 boxes to 3 boxes which under expected usage levels provides a sufficient supply for more than 24 hours.”

    Source location

    Response from Royal Free Hospital
    Page 2 · response
    Published 1 April 2025

    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

    Increase ward 8 North Naloxone stock from two to three boxes and audit stocking consistency.

    Verbatim wording from the response

    “Clarity on the process of accessing Naloxone, including out of hours, should stock need replenishing will be shared at daily huddles for two weeks. In addition, pharmacy will be increasing the stock level on 8 North ward to reduce the likelihood of it not being immediately available. Stock levels have been increased from 2 boxes to 3 boxes which under expected usage levels provides a sufficient supply for more than 24 hours.”

    Source location

    Response from Royal Free Hospital
    Page 2 · response
    Published 1 April 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

    Access to Naloxone on ward 8 North was not disrupted; unusually high usage caused the delay in administration.

    Verbatim wording from the response

    “Access to Naloxone during Dr Rahman’s time on 8 North was not reported to be disrupted and his medication chart records that it was administered to him between 24 minutes and 1 hour following the prescription being made, despite the significant quantity that was used. It was concluded that this was a highly unusual circumstance, in which Dr Rahman was receiving ongoing infusions, requiring an unusually large quantity of Naloxone, as a result impacting the time to administer.”

    Source location

    Response from Royal Free Hospital
    Page 2 · response
    Published 1 April 2025

    Open published response
  2. West Yorkshire Eastern

    AI-generated summary

    David Joseph Crompton · 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 Joseph Crompton, who had epilepsy, was left without his prescribed Tegretol for approximately 10 days in April 2024 and again in December 2024. His falls in both periods occurred when he was without the medication, and the inquest recorded a fall downstairs on 13 December 2024, with causes of death including hypoxic ischaemic encephalopathy, out-of-hospital cardiac arrest and cervical spine injury. The principal concerns were delays in supplying essential anti-epileptic medication, reliance on family members to seek alternative supplies, and the absence of clear systems for managing medication shortages.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of clear designated systems for dealing with medication supply shortages

    Wider context from the report

    “(4) Comment was made at the inquest to the effect that the pharmaceutical profession should have clear designated systems to deal with any shortages of supply encountered; for example, reference to hospital departments to ensure patients are not left without important medications. Leaflets explaining the role of those concerned in this situation were not provided. ”

    Source location

    David Joseph Crompton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide leaflets explaining roles during medication supply shortages

    Wider context from the report

    “(4) Comment was made at the inquest to the effect that the pharmaceutical profession should have clear designated systems to deal with any shortages of supply encountered; for example, reference to hospital departments to ensure patients are not left without important medications. Leaflets explaining the role of those concerned in this situation were not provided. ”

    Source location

    David Joseph Crompton · 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 pharmacies to search for supplies when prescribed medication is unavailable

    Wider context from the report

    “(2) The evidence given by family members at the inquest was that when the pharmacy was unable to supply the prescribed Tegretol medication, it was left to them to contact other pharmacies to see if they could obtain it, rather than for the pharmacy to search for supplies. ”

    Source location

    David Joseph Crompton · 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

    Publish guidance explaining how pharmacies should respond when prescribed medicines are unavailable.

    Verbatim wording from the response

    “In November 2024 we published an article about medicines shortage, https://www.pharmacyregulation.org/about-us/news-and-updates/regulate/struggle-around-medicines-shortages The article states that if the pharmacy is unable to supply a particular medicine stated on prescription then they should talk to the patient to discuss their options. The article outlines examples of steps that pharmacy should take.”

    Source location

    Response from General Pharmaceutical Council
    Page 2 · response
    Published 9 January 2025

    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

    Inspect the pharmacy’s systems for managing out-of-stock medicines and supply issues.

    Verbatim wording from the response

    “The particular pharmacy has been inspected by our Inspection Team, who looked for evidence that the pharmacy was meeting our Standards for Registered Pharmacies. The purpose of these standards is to create and maintain the right environment in pharmacies to protect and improve people’s health and wellbeing. The inspection included looking for evidence about the systems in place to manage medicines which were out of stock at the pharmacy and where there were supply issues at the wholesalers. This was to ensure practices in the pharmacy relating to stock management were appropriate.”

    Source location

    Response from General Pharmaceutical Council
    Page 2 · response
    Published 9 January 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 pharmacy’s staged process sought medication supplies, and referral to other pharmacies followed unsuccessful attempts to obtain the prescribed brand.

    Verbatim wording from the response

    “(2) The evidence given by family members at the inquest was that when the pharmacy was unable to supply the prescribed Tegretol medication, it was left to them to contact other pharmacies to see if they could obtain it, rather than for the pharmacy to search for supplies.”

    Source location

    Response from Midway Pharmacy
    Page 2 · response
    Published 9 January 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

    Manufacturing medicines and wider supply and shortage issues fall outside the regulator’s direct role.

    Verbatim wording from the response

    “We are aware of supply issues with some Tegretol products. While we do not have a direct role in the manufacturing of medicines or wider issues such as supply and shortages, we understand that medicines shortages can cause problems for patients and carers. We know that pharmacy professionals are also concerned and have to use their professional judgement and make decisions in challenging situations, balancing a range of factors such as individual patient needs and available supplies of medicines. Our standards require pharmacy professionals to deliver patient-centred care, which includes making the care of the patient their first concern and using their judgement to make professional decisions. This may include making decisions about providing medication in an emergency.”

    Source location

    Response from General Pharmaceutical Council
    Page 2 · response
    Published 9 January 2025

    Open published response
  3. Leicester City and South Leicestershire

    AI-generated summary

    Rafal Delezuch · 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

    Rafal Delezuch was seen behaving bizarrely and showing paranoia in Leicester before being restrained by police under section 136 of the Mental Health Act and taken to hospital. The inquest concluded that he died from amphetamine-induced delirium in association with prolonged struggle. Concerns included staff awareness and training on restraint, lack of familiarity with the dangers of prolonged prone restraint, difficulties obtaining and selecting medication for rapid tranquillisation, and an overlooked warning about diazepam in NICE guidance.

    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 priority access to limited supplies of Lorazepam

    Wider context from the report

    “(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy. (2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position (3) When it was decided that the patient was in need of rapid tranquilisation then: a) A supply of Lorazepam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazepam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated. (4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked. ”

    Source location

    Rafal Delezuch · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  4. Manchester South

    AI-generated summary

    Mary Fenton · 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

    Mary Fenton was admitted to Tameside Hospital on 26 April 2014 needing an urgent heart pacemaker and died on 30 April 2014 after delays and missed opportunities. Concerns included limited cardiology cover and facilities, shortages of Isoprenaline, failures relating to capacity and consent, delays in inserting pacing wires, inadequate facilities to manage complications, and poor communication.

    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

    Severe shortages of Isoprenaline

    Wider context from the report

    “3. This patient was being kept alive by the use of Isoprenaline. It transpires that there were severe shortages of this drug in the hospital but also nationally. I was told that this drug is produced as an unlicensed drug by NHS Pharmaceutical Productions. If so why do they not ensure sufficient supply? (For Tameside Hospital and for The Secretary of State) ”

    Source location

    Mary Fenton · 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

    Work with European and North American countries to resolve pharmaceutical supply issues.

    Verbatim wording from the response

    “Supply issues are complex and most have to be dealt with on a case by case basis but in recognising the main problems it is possible to take action to mitigate them. Our Government is currently working with other countries in Europe and with North America to resolve some of these supply issues.”

    Source location

    2014-0443-Response-by-Department-of-Health
    Page 2 · response
    Published 13 October 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

    Ask the NHS UK Medicines Information service to produce a shortage memorandum on isoprenaline availability and alternative supply sources.

    Verbatim wording from the response

    “The Department of Health is aware that there have been problems with the availability of isoprenaline and that earlier this year the NHS PMUs experienced problems obtaining the active pharmaceutical ingredient. The Department of Health therefore asked the NHS UK Medicines Information service (UKMI) to produce a “Shortage Memo” which summarises the situation and advises on alternative sources of supply. This was sent out to hospitals and uploaded to the UKMI website, at the following address, on 24 April 2014:-”

    Source location

    2014-0443-Response-by-Department-of-Health
    Page 2 · response
    Published 13 October 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

    Replenish the Trust’s Isoprenaline stock following the national shortage.

    Verbatim wording from the response

    “The Trust currently keeps a supply of 200 ampoules of Isoprenaline supplies in stock. This would last a patient approximately 17 calendar days if prescribed in the same dosage as that provided to Mrs Fenton. The Trust has replenished its stocks following the end of the national alert on the Isoprenaline shortage due to manufacturing difficulties in August/September 2014. Actions have also been taken to ensure that within Critical Care there is safe storage”

    Source location

    2014-0443-Response-by-Tameside-Hospital
    Page 2 · response
    Published 13 October 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

    Maintain safe Critical Care medication storage, regular staff checks and pharmacist audits.

    Verbatim wording from the response

    “The Trust currently keeps a supply of 200 ampoules of Isoprenaline supplies in stock. This would last a patient approximately 17 calendar days if prescribed in the same dosage as that provided to Mrs Fenton. The Trust has replenished its stocks following the end of the national alert on the Isoprenaline shortage due to manufacturing difficulties in August/September 2014. Actions have also been taken to ensure that within Critical Care there is safe storage”

    Source location

    2014-0443-Response-by-Tameside-Hospital
    Page 2 · response
    Published 13 October 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

    Reiterate the medicines-shortage protocol to the Pharmacy Department.

    Verbatim wording from the response

    “Also, the Trust does have a protocol in place which is followed when any shortage arises. This involves conducting a risk assessment to evaluate the potential effect of the shortage and the assessment takes account of the estimated duration of the shortage; usage figures; the availability of suitable alternative products; and the potential risk to patients. As you will appreciate, not all shortages will need further action but where the risk assessment supports further work on a long term critical shortage, the Trust’s Pharmacy Department makes an estimate of the stock in hand within the entire organisation and of the time period this will cover. Where limited stock might lead to a restriction being placed on the use of a medicine, then this restriction will be discussed and agreed with the most relevant and appropriate Senior Doctor within the Trust.”

    Source location

    2014-0443-Response-by-Tameside-Hospital
    Page 3 · response
    Published 13 October 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

    Review existing Pharmacy Department pathways for managing medicines shortages.

    Verbatim wording from the response

    “Please be assured that the Trust finds any shortage of drugs unacceptable and we are doing everything within our power to ensure such shortages do not impact upon the care our patients receive. The Trust does have a strong contingency plan in place and in the case of Mrs Fenton this was evidenced by the incident itself where the Trust utilised local networks to ensure continuity of supply. Following the inquest into the death of Mrs Fenton, the Trust has reviewed all existing pathways to the Pharmacy Department and we cannot identify a case where the Trust has not been able either a medicine experiencing a shortage or a clinically appropriate and suitable agreed alternative for a patient.”

    Source location

    2014-0443-Response-by-Tameside-Hospital
    Page 4 · response
    Published 13 October 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

    Some medicine supply problems are inevitable and unavoidable because of manufacturing, regulatory and raw-material difficulties.

    Verbatim wording from the response

    “Medicines shortages are not new, nor are they confined to the UK. There are a number of reasons why such shortages do arise but the two main reasons are commonly referred to as ‘upstream’ and ‘downstream’:-”

    Source location

    2014-0443-Response-by-Department-of-Health
    Page 2 · response
    Published 13 October 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

    Existing stocks, contingency arrangements and local networks are considered sufficient to maintain medicines or suitable alternatives during shortages.

    Verbatim wording from the response

    “The Trust currently keeps a supply of 200 ampoules of Isoprenaline supplies in stock. This would last a patient approximately 17 calendar days if prescribed in the same dosage as that provided to Mrs Fenton. The Trust has replenished its stocks following the end of the national alert on the Isoprenaline shortage due to manufacturing difficulties in August/September 2014. Actions have also been taken to ensure that within Critical Care there is safe storage”

    Source location

    2014-0443-Response-by-Tameside-Hospital
    Page 2 · response
    Published 13 October 2014

    Open published response
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Data last updated 7 September 2026