Recurring concern

Unreliable fulfilment of hospital-issued medication prescriptions

First to latest report 5 May 2021 — 21 May 2026

Reports that mention this concern: 2
Times this concern has been raised: 2
Stated actions linked to this concern: 3

What this concern includes

Includes delays, non-fulfilment, failure to establish fulfilment, or other dedicated processing and supply failures affecting hospital-issued medication prescriptions.

What is not included

Excludes generic failures in prescription regulation, guidance or sanctions that are not specifically tied to fulfilment of a hospital-issued medication prescription.
Excludes failures involving prescriptions that were not issued by a hospital.
Excludes medication-supply problems unrelated to prescription fulfilment, such as stock access or prescribing decisions.

Trends

Reports over time

Reports mentioning this concern, 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

HM Prison and Probation Service1

Ministry of Justice1

Oxleas NHS Foundation Trust1

Sandwell and West Birmingham Hospitals NHS Trust1

The Verne Prison1

Reports and published responses 2 reports

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

21 May2026
Dorset
Concerns raised1
1. Delays in processing hospital-issued FP10 prescriptions in prisons without 24-hour healthcare provision
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Department of Health and Social Care
Ministry of Justice
NHS England
Oxleas NHS Foundation Trust
The Verne Prison
Stated actions 3
1. Oxleas NHS Foundation Trust
  Implement the Southwest Out of Hours SOP for sourcing prescribed medicines outside normal operating hours.
2. Oxleas NHS Foundation Trust
  Recirculate the Southwest Out of Hours SOP and associated guidance to all healthcare teams.
3. Ministry of Justice and The Verne Prison
  Continue collaborative work between prison and healthcare managers to establish local out-of-hours medication processes with defined escalation routes, roles and accountability.
Respondent positions 4
1. Oxleas NHS Foundation Trust
  Existing governance and operational guidance address the concerns about obtaining prescribed medication outside normal working hours.
  Existing arrangements considered sufficient
1. NHS England
  Prison teams are responsible for arranging pickup or delivery of urgent out-of-hours medicines.
  Redirects responsibility
2. Department of Health and Social Care
  NHS England is responsible for addressing concerns about obtaining hospital-prescribed medication out of hours in prisons without 24-hour healthcare.
  Redirects responsibility
3. Ministry of Justice and The Verne Prison
  Responsibility for the out-of-hours medication process has been referred to Oxleas NHS Foundation Trust for consideration and response.
  Redirects responsibility
AI-generated summary

George Edward James Haldenby · 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

George Edward James Haldenby was a serving prisoner with severe heart failure who collapsed at HMP The Verne on 29 January 2022 and died that day at Dorset County Hospital. The report identifies delays in receiving an increased dose of Furosemide, and a delay in recognising the collapse and starting CPR, as substantive concerns. It also raises concerns about the absence of regular refresher training in first aid and CPR and the lack of a clear process for handling hospital prescriptions issued outside prison healthcare hours.

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
Delays in processing hospital-issued FP10 prescriptions in prisons without 24-hour healthcare provision
Wider context from the report
“In prisons without 24 hour healthcare provision, if a prisoner receives treatment at a hospital and is issued with a medication prescription on a FP10 form, this cannot be processed at the prison in the absence of a doctor or prescribing nurse, and pharmacies in hospitals are not always open 24 hours a day for it to be dispensed as TTO medication. This means there will be a delay in prisoners receiving necessary and lifesaving medication over a weekend or bank holiday period until staff are in the prison who can action the prescription. ”
Source location
George Edward James Haldenby · 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
Implement the Southwest Out of Hours SOP for sourcing prescribed medicines outside normal operating hours.

Verbatim wording from the response
“Following a review of these concerns, we can confirm that a formal process has been in place across the Southwest region since September 2024 through the implementation of the Southwest Out of Hours Standard Operating Procedure (SOP)- (Appendices 1). This SOP was circulated to all relevant healthcare teams upon implementation and remains accessible through the organisational document management systems, including the Ox and the SystmOne Pharmacy Document Library.”

Source location
2026-0312 - Response from Oxleas NHS Foundation Trust
Page 2 · response
Published 14 August 2026
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
Recirculate the Southwest Out of Hours SOP and associated guidance to all healthcare teams.

Verbatim wording from the response
“In addition, this incident has provided an opportunity to further reinforce awareness of existing medicines management policies and SOPs. The Southwest Out of Hours SOP and associated guidance will be recirculated to all healthcare teams, and ongoing training sessions will continue to reinforce staff understanding and compliance. The Medicines Management SOP Log will also be redistributed to all Heads of Healthcare to improve visibility of current medicines-related procedures, alongside signposting staff to the centrally maintained document repository where the most up-to-date versions are held.”

Source location
2026-0312 - Response from Oxleas NHS Foundation Trust
Page 2 · response
Published 14 August 2026
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 collaborative work between prison and healthcare managers to establish local out-of-hours medication processes with defined escalation routes, roles and accountability.

Verbatim wording from the response
“Further collaborative work is being undertaken between prison and healthcare managers to establish a clear and robust local process incorporating defined escalation routes, roles and accountability measures. This will ensure that staff have the necessary clarity and confidence to respond appropriately when out-of-hours medication issues arise, supporting timely access to essential treatment and continuity of care.”

Source location
2026-0312 - Response from HM Prison and Probation Service
Page 2 · response
Published 14 August 2026
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 governance and operational guidance address the concerns about obtaining prescribed medication outside normal working hours.

Verbatim wording from the response
“Following a review of these concerns, we can confirm that a formal process has been in place across the Southwest region since September 2024 through the implementation of the Southwest Out of Hours Standard Operating Procedure (SOP)- (Appendices 1). This SOP was circulated to all relevant healthcare teams upon implementation and remains accessible through the organisational document management systems, including the Ox and the SystmOne Pharmacy Document Library.”

Source location
2026-0312 - Response from Oxleas NHS Foundation Trust
Page 2 · response
Published 14 August 2026
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
Prison teams are responsible for arranging pickup or delivery of urgent out-of-hours medicines.

Verbatim wording from the response
“Under the pharmacy and medicines optimisation section of the specification, it sets out that the provider is required to arrange and use a process for the dispensing of urgent medication from local pharmacies, or other urgent care or OOH primary care services, outside of core hours (including public holidays). This should be available on request although pick up/delivery of the medicines must be arranged by the prison teams.”

Source location
2026-0312 - Response from NHS England
Page 2 · response
Published 14 August 2026
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
NHS England is responsible for addressing concerns about obtaining hospital-prescribed medication out of hours in prisons without 24-hour healthcare.

Verbatim wording from the response
“The report raises concerns about the lack of process in place in prisons without 24-hour healthcare provision, to ensure that hospital prescribed medication is available when prescribed out of hours, and over weekends and bank holiday periods.”

Source location
2026-0312 - Response from Department of Health and Social Care
Page 1 · response
Published 14 August 2026
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
Responsibility for the out-of-hours medication process has been referred to Oxleas NHS Foundation Trust for consideration and response.

Verbatim wording from the response
“Although your concerns about the lack of policy/process for healthcare staff around accessing out of hours or hospital prescribed medication has been referred to Oxleas NHS Foundation Trust for their separate consideration and response, HMPPS has also considered whether there is any supportive action that it can take. Oxleas NHS Foundation Trust has confirmed that a formal process and guidance for healthcare teams regarding the management of medicines outside normal operating hours was implemented in September 2024. This is supported by a Standard Operating Procedure, which provides clear direction on the sourcing and provision of prescribed medication during evenings, weekends, and bank holidays.”

Source location
2026-0312 - Response from HM Prison and Probation Service
Page 2 · response
Published 14 August 2026
Open published response
5 May2021
Black Country
Concerns raised1
1. Failure to verify fulfilment of hospital-issued medication prescriptions
This report raised 1 other concern. 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.
AI-generated summary

Sarah Brady · 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

Sarah Brady, a 75-year-old woman, was admitted to hospital on 4 August 2020 after being found unresponsive at home following a presumed medication overdose. She deteriorated into multi-organ failure and died in hospital on 8 August 2020. The concerns included prescriptions exceeding the GP’s seven-day limit despite her history of overdose and erratic medication compliance, possible stockpiling of medication, and uncertainty about whether an additional hospital prescription had been fulfilled.

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 verify fulfilment of hospital-issued medication prescriptions
Wider context from the report
“(2) Due to the above, Mrs Brady’s GP was only issuing 7 day prescriptions due to her high risk of overdose in order to limit medication availability. This included ████████ ████████ amongst others. (3) Mrs Brady had already been issued with a prescription by her GP on 14/7/20 for her regular prescription medication; (4) The inquest heard evidence that following a hospital admission in early July 2020, Mrs Brady was medically fit for discharge on 15/7/20 and a prescription was issued by the Sandwell & West Birmingham Hospital Trust for 14 days of ████████ ████████████████████████████████████████████████████████████████████████ ████████ (4) It was unclear from the evidence whether the prescription had actually been fulfilled by the hospital. I am concerned that Mrs Brady was issued with a prescription in excess of 7 days and for medication that had already been prescribed to her by her GP only the previous day and against a background of overdose and erratic compliance with her medications; (5) The levels of ████████ found as a result of qualitative testing appeared to be well in in excess of her prescriptions and there was evidence that Mrs Brady may have been stockpiling medication. It is possible that the additional prescription, if supplied may have formed part of the medication taken by way of overdose. (6) I heard at inquest that another similar prescription issued on 28/7/20 following a further admission had NOT been fulfilled. ”
Source location
Sarah Brady · Prevention of Future Deaths report
Page 2 · concerns
Open source report