21 May 2024 Tracy Frances MCCARTHY · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Prescribing of amitriptyline above the maximum suggested dose for a patient known to be dependent on it View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Tracy Frances MCCARTHY · Prevention of Future Deaths report
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Report summary
Tracy McCarthy was found deceased at home on 17 July 2023 and died from long-term misuse of amitriptyline; the inquest conclusion was a drug-related death, with amitriptyline toxicity and coronary artery disease recorded. The concerns included prescribing amitriptyline above the maximum suggested dose, failure to flag the overdose risk and stop or appropriately manage the prescription, and changing from daily to monthly prescriptions despite recognised risks.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Prescribing of amitriptyline above the maximum suggested dose for a patient known to be dependent on it
Wider context from the report “(1) Although Amitriptyline is not generally regarded as a drug of abuse, Ms McCarthy was known to be dependent on it . She had been prescribed Amitriptyline for many years, and at one stage in or about 2022, she was regularly prescribed ████████ mg per day, which is over the maximum suggested dose in the BNF (150mg per day) . In addition, the BNF provides a clear warning (as did the prescribing/records software in use at The Tredegar Practice) that Amitriptyline prescribed for depression (which it was in this case), is “not recommended – increased risk of fatality in overdose”. A GP from The Tredegar Practice told me that ████████ mg was an “unacceptable dose” .
The concern being that guidelines were not followed, particularly in relation to a patient known to be dependent and where use of Amitriptyline was not recommended for the presenting condition in any event.
” Source location Tracy Frances MCCARTHY · Prevention of Future Deaths report
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6 Nov 2020 Stanley Alfred Babbs · Prevention of Future Deaths report East London
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Concerns raised 1
Lack of careful consideration of contrast medium dose View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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Stanley Alfred Babbs · Prevention of Future Deaths report
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Report summary
Stanley Alfred Babbs, who had chronic kidney disease, diabetes and heart failure, became unwell after receiving contrast for a CT scan and was diagnosed with contrast-induced acute kidney injury. He was later admitted to hospital and died from sepsis arising from a urinary tract infection on 16 February 2016. The report raised concerns that contrast, a prescription-only medicine, could be administered without a formal prescription, individualised risk/benefit assessment, careful dose consideration or a clearly identified responsible clinician, particularly for patients at high risk of acute kidney injury.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of careful consideration of contrast medium dose
Wider context from the report “The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it.
The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight .
It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).
The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast. This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.
Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription, evidence of a careful consideration of the dose and a clearly identified responsible clinician.
” Source location Stanley Alfred Babbs · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specify contrast dosing at 1 ml/kg up to a 100 ml maximum.
Verbatim wording from the response “• Contrast Dose: now specified as 1ml/Kg with maximum of 100ml (medical scales have been ordered for all scanners and should be in place soon). (As per action 12 on plan)” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide medical scales for all scanners to support the specified contrast dosing.
Verbatim wording from the response “• Contrast Dose: now specified as 1ml/Kg with maximum of 100ml (medical scales have been ordered for all scanners and should be in place soon). (As per action 12 on plan)” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
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Concerns raised 2
Lack of agreed use of beds with weight-indicating scales to support accurate medication dosing View source Failure to accurately record or obtain patient weight for weight-dependent anticoagulant dosing View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Scott Douglas Hooper · Prevention of Future Deaths report
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Report summary
Scott Douglas Hooper, aged 46, died on 22 March 2016 after sustaining complex pelvic fractures in an unwitnessed workplace forklift accident and later suffering a pulmonary embolism and deep vein thrombosis. The principal concerns were that his weight was incorrectly recorded, affecting the prescribed anticoagulant dose, and that a decision to withhold a dose was not recorded with the decision-maker identified.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of agreed use of beds with weight-indicating scales to support accurate medication dosing
Wider context from the report “1. On admission to SGH on 12 March, Mr Hooper's weight was incorrectly recorded as 80kg when the reality was his true weight was 107 kg – a difference of 27 kg (or 3.5lbs) which is a considerable difference. This is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis protocol is calculated on weight.
2. As stated above, on 15 March when the clinical decision was made to withhold the morning dose of Tpx medication it could not be ascertained who made the decision. This was a significant clinical decision and it is a basic requirement that all clinical decisions are recorded in order to capture capturing who made the decision and why.
In respect of both of these concerns, during the investigation I learned through the Root Cause Analysis that a Trauma & Orthopaedic Morbidity & Mortality meeting had been held.
In addition, I was told during the inquest that a nonogram was now in use to improve weight estimation for those patients where it was not possible to obtain actual weight and that training was underway in relation to its use for elderly patients. I also heard that some new beds with built in weight indicating scales were to be purchased within 2 months subject to cost and commissioning.
Whilst a valuable tool, a single T&O M&M meeting is only effective for those doctors and nursing staff who attend. I was not given any other detail as to how the valuable lessons to be learned from this case were to be spread to clinical staff across the T&O department or the whole Trust as weight estimation can be equally important in many other medical specialisms.
I was told during the inquest that training was currently taking place in respect of elderly patients but I was not given a plan or timetable for other high risk patients such as Mr Hooper who was only 46 years old and suffered from an acute crush pelvic trauma which had the potential to be life threatening. Mr Hooper died on 22 March 2016 but as yet no active steps have been taken to address patients who fall into the same category.
The same principle can be said to apply to bed purchase and it did not appear to be an agreed action that beds with scales would be used to improve the problem of weight estimation in order to ensure accurate dosage of essential medication .
” Source location Scott Douglas Hooper · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to accurately record or obtain patient weight for weight-dependent anticoagulant dosing
Wider context from the report “1. On admission to SGH on 12 March, Mr Hooper's weight was incorrectly recorded as 80kg when the reality was his true weight was 107 kg – a difference of 27 kg (or 3.5lbs) which is a considerable difference. This is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis protocol is calculated on weight .
2. As stated above, on 15 March when the clinical decision was made to withhold the morning dose of Tpx medication it could not be ascertained who made the decision. This was a significant clinical decision and it is a basic requirement that all clinical decisions are recorded in order to capture capturing who made the decision and why.
In respect of both of these concerns, during the investigation I learned through the Root Cause Analysis that a Trauma & Orthopaedic Morbidity & Mortality meeting had been held.
In addition, I was told during the inquest that a nonogram was now in use to improve weight estimation for those patients where it was not possible to obtain actual weight and that training was underway in relation to its use for elderly patients. I also heard that some new beds with built in weight indicating scales were to be purchased within 2 months subject to cost and commissioning.
Whilst a valuable tool, a single T&O M&M meeting is only effective for those doctors and nursing staff who attend. I was not given any other detail as to how the valuable lessons to be learned from this case were to be spread to clinical staff across the T&O department or the whole Trust as weight estimation can be equally important in many other medical specialisms.
I was told during the inquest that training was currently taking place in respect of elderly patients but I was not given a plan or timetable for other high risk patients such as Mr Hooper who was only 46 years old and suffered from an acute crush pelvic trauma which had the potential to be life threatening. Mr Hooper died on 22 March 2016 but as yet no active steps have been taken to address patients who fall into the same category.
The same principle can be said to apply to bed purchase and it did not appear to be an agreed action that beds with scales would be used to improve the problem of weight estimation in order to ensure accurate dosage of essential medication.
” Source location Scott Douglas Hooper · Prevention of Future Deaths report
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Concerns raised 1
Failure to adjust paracetamol dosage for extremely low body weight View source
Linked response
the Rotherham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
the Rotherham NHS Foundation Trust
Review the Medicines Management Policy and develop local guidance, a standard operating procedure, or directive covering dose reduction for extremely low body weight.
View source
the Rotherham NHS Foundation Trust
Produce and disseminate pharmacy and junior-medical-staff information on reducing oral paracetamol doses for patients under 50 kilograms or with relevant risk conditions.
View source
the Rotherham NHS Foundation Trust
Develop prescription-chart stickers to raise awareness of oral and intravenous paracetamol dose-reduction guidance.
View source
the Rotherham NHS Foundation Trust
Develop information for nursing and medical staff on adjusting paracetamol dosage for adult patients with extremely low body weight.
View source
the Rotherham NHS Foundation Trust
Provide and record required staff training on paracetamol dose reduction, including training during induction.
View source
the Rotherham NHS Foundation Trust
Audit documentation of patient weights in clinical, nursing, and prescription records and present the results to the Patient Safety Group.
View source
the Rotherham NHS Foundation Trust
Deliver a learning event discussing the specific case as part of the September safety programme.
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Hayley Christine Clark · Prevention of Future Deaths report
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Report summary
Hayley Christine Clark, aged 36, was admitted to Rotherham General Hospital with electrolyte imbalance and received an unadjusted standard adult dose of paracetamol despite her extremely low body weight. Her condition deteriorated and she died on 24 May 2015; the inquest recorded severe multifactorial malnutrition among the causes of death. The substantive concern was that staff failed to recognise the need to reduce the paracetamol dosage for her low body weight.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to adjust paracetamol dosage for extremely low body weight
Wider context from the report “(1) There was a failure, on the part of the staff who prescribed and administered the Paracetamol to Ms Clark, to recognise the need to adjust the dosage (in evidence the required reduction was said to be 50%) to reflect Ms Clark’s extremely low body weight .
” Source location Hayley Christine Clark · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Medicines Management Policy and develop local guidance, a standard operating procedure, or directive covering dose reduction for extremely low body weight.
Verbatim wording from the response “1. Ensure the Trust’s Medicines Management Policy includes the safe prescribing and administration of medication for patients with extremely low body weight.” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and disseminate pharmacy and junior-medical-staff information on reducing oral paracetamol doses for patients under 50 kilograms or with relevant risk conditions.
Verbatim wording from the response “1.2 A pharmacy medications information leaflet to be produced on reducing the dose of oral paracetamol for patients who weigh less than 50kgs and/or with medical conditions which may require consideration of dose reduction – malnutrition/anorexia or high alcohol consumption all of which are known indications for considering a dose reduction of oral paracetamol” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop prescription-chart stickers to raise awareness of oral and intravenous paracetamol dose-reduction guidance.
Verbatim wording from the response “1.3 Development of stickers to be used on the Trust’s prescription charts to raise awareness and compliance with the dose reduction guidance of oral (and IV) paracetamol” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop information for nursing and medical staff on adjusting paracetamol dosage for adult patients with extremely low body weight.
Verbatim wording from the response “2. Ensure all nursing and medical colleagues identify adult patients with extremely low body weight who may need adjustment in the dosage of oral paracetamol” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide and record required staff training on paracetamol dose reduction, including training during induction.
Verbatim wording from the response “2.2 A record of all staff who require and have received appropriate training - on dosage reduction; will be collated to ensure all appropriate nursing and medical colleagues have received this in the required timescale” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit documentation of patient weights in clinical, nursing, and prescription records and present the results to the Patient Safety Group.
Verbatim wording from the response “2.3 Review of documentation to ensure accurate recording of patients weight in the clinical records, nursing records and prescription charts” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a learning event discussing the specific case as part of the September safety programme.
Verbatim wording from the response “2.5 A learning event to be held to discuss the details of this specific case” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Body weight alone is not considered a marker of increased risk of oral paracetamol toxicity, although associated conditions may warrant dose reduction.
Verbatim wording from the response “What timescale has been set and agreed?
As the British National Formulary (BNF) does not currently provide dosage reduction recommendations the Trust’s Chief Pharmacist has sought advice from the Medicines and Healthcare products Regulatory Agency (MHRA) who have recently reviewed the publication of a paper from Birmingham Trust; whilst body weight alone is not considered a marker for an increased risk of oral paracetamol toxicity, an adult weighing less than 50kgs is more likely to have conditions that predispose them to liver damage from the paracetamol. A dose reduction to 2-3g total daily dose may be warranted. The MHRA are not currently recommending a change to the licences of oral paracetamol products, or a change to the packaging of the paracetamol products for the public to buy.” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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Concerns raised 1
Failure of prescribers to apply the maximum tramadol dose for people over 75 View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Kathleen Cornthwaite · 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 Cornthwaite, aged 76, was an inpatient at Pendle Community Hospital when her tramadol prescription was increased after a fall causing a rib injury. The inquest concluded that she died of cardiorespiratory failure due to combined tramadol and fluoxetine toxicity. Concerns included the imprecise tramadol dose recorded, failure to account for her age, size and frailty, and failure to consider interactions with other prescribed medicines.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of prescribers to apply the maximum tramadol dose for people over 75
Wider context from the report “2. That the doctor prescribing was not aware of the maximum dose of tramadol for somebody over 75 years of age and failed to take into account her size and frailty.
” Source location Kathleen Cornthwaite · Prevention of Future Deaths report
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11 Jun 2014 Bridget May CAHILL · Prevention of Future Deaths report Black Country
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Concerns raised 1
Failure to individualise maximum morphine doses to body weight, comorbidities and other relevant factors View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Medicines and Healthcare products Regulatory Agency
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Bridget May CAHILL · Prevention of Future Deaths report
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Report summary
Bridget May CAHILL died in hospital from a morphine overdose after being admitted with unresponsiveness and receiving treatment including naloxone. The principal concern was how a patient prescribed and receiving less than the maximum permitted morphine dose could nevertheless suffer an overdose, including whether dosing should account for factors such as body weight, comorbidities, and possible accumulation during long-term therapy.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to individualise maximum morphine doses to body weight, comorbidities and other relevant factors
Wider context from the report “The evidence I heard was that Mrs. Cahill was admitted to Walsall Manor Hospital on 10th September 2013. She had a one day history of unresponsiveness, had a background of Parkinson’s disease, dementia and chronic backache. She lived in a residential home. On admission she had pinpoint pupils suggesting morphine overdose which was partially reversed with an antidote. Blood tests showed high calcium levels suggestive of dehydration, or possibly a tumour and there was a suggestion of possible ongoing infection. She had treatment with IV fluids, IV antibiotics and Naloxone, but she deteriorated and died. She was on morphine night and morning and also oral morphine during the day if and when required. The maximum dose of Oramorph was 20 millilitres per day, 5 millilitres at a time, dosages to be 4 to 6 hours apart. The evidence I heard was that at no time prior to her death did she have the maximum permitted dose.
My concern relates to how it is that a person who is prescribed morphine and who has less than the amount prescribed for them, can nevertheless suffer an overdose. I write to enquire whether attention needs to be given to the maximum dose that can be recommended and whether it is, or should be, subject to factors such as body weight, any co morbidities and any other factors and whether attention should be directed towards the possible buildup of morphine in the body for those involved in long-term therapy.
” Source location Bridget May CAHILL · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation This case does not prompt a review of the maximum permitted morphine dose because analgesic requirements vary and tolerance develops with chronic administration.
Verbatim wording from the response “This case does not prompt a review of the maximum permitted dose given the interindividual range of dose needed to achieve analgesia and the tolerance that is expected to develop as a result of chronic morphine administration.” Source location 2015-0266-Response-by-MHRA
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maximum morphine dosing need not be adjusted for body weight or comorbidities because prescribing information already advises dose reduction in specified circumstances.
Verbatim wording from the response “2. Should the maximum dose be subject to factors such as body weight and any co-morbidities?” Source location 2015-0266-Response-by-MHRA
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9 May 2014 Linda Yvonne Fisher · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 1
Failure to accurately determine patient weight for medication dosage View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Linda Yvonne Fisher · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Linda Yvonne Fisher was admitted to hospital with knee pain and was treated for a suspected deep vein thrombosis. She was found collapsed on 17 October 2013 and died from a pulmonary embolism. Concerns related to medication dosages being based on inaccurately assessed patient weight and relevant family medical history not being obtained and communicated effectively.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to accurately determine patient weight for medication dosage
Wider context from the report “1. The inquest heard evidence that patients may be admitted to hospital who, once medically assessed, may require medication the dosage of which may be determined by the weight of that patient. On occasion such a patient may not be able to be weighed in order to determine their weight, perhaps for example due to a leg injury that prevents the patient bearing their own weight for long enough to allow medical staff to weigh them. In such circumstances, a Doctor placed reliance upon the Deceased’s own verbal assessment of her own weight and used this information to decide upon the medication dosage. Although I was informed that the Trust is aware of this issue and have considered one method of resolving it [which I understand is not to be implemented], I remain concerned that patients may be prescribed medications at a dosage which is inaccurately determined due to the fact that a patient has incorrectly assessed their own weight , and if patients do not receive the correct dosage future deaths may result.
” Source location Linda Yvonne Fisher · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Perform Mid Upper Arm Circumference calculations using MUST when patients cannot be weighed, to assist in establishing accurate weight.
Verbatim wording from the response “As you were advised at the inquest the Ward staff, now, in addition to obtaining verbal confirmation of a patients weight, if it is not possible to weigh the patient, a Mid Upper Arm Circumference calculation is performed (MUAC) in line with the malnutrition Universal Screening Tool (MUST) to assist in establishing an accurate weight.” Source location 2014-0226-Response-by-Blackpool-Teaching-Hospitals
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Exact patient weight is not required for dalteparin dosage; verbal weight assessment is acceptable when physical weighing is not possible.
Verbatim wording from the response “1) That we may rely upon patient’s verbal assessment of their own weight to determine medication dosage.” Source location 2014-0226-Response-by-Blackpool-Teaching-Hospitals
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.