Recurring concern

Unreliable application of TOXBASE toxicology guidance

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First reported 14 Sep 2018•Latest report 4 Feb 2022

Definition

What this concern includes

Includes failures of the dedicated TOXBASE guidance process in overdose care, including access to relevant guidance, interpretation of treatment by time since ingestion, application to re-presentations, recognition of time-critical treatment and escalation of the emergency response.

Not included

  • Excludes generic overdose assessment, treatment or escalation failures where TOXBASE or its dedicated guidance process is not materially deficient.
  • Excludes clinical guidance and toxicology systems unrelated to TOXBASE unless the assertion explicitly concerns the same TOXBASE application process.
  • Excludes factual toxicity hazards, such as the absence of an antidote, where no failure to apply TOXBASE guidance is identified.
  • Excludes downstream treatment failures after relevant TOXBASE guidance has been reliably accessed and applied.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2018–2022

First to latest report issue date

Stated actions
2

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.

TOXBASE1
Welsh Ambulance Services 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. South Wales Central

    AI-generated summary

    Sarah Marie GILBERT-JONES · 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 Marie GILBERT-JONES died in the early hours of 29 October 2020 after taking a significant overdose of prescription medication with alcohol. The report raised concerns about delays and inconsistent categorisation in the emergency response, including failure to recognise that treatment was time critical, and about sub-optimal mental health service provision.

    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 clinical review to use toxicology information to identify time-critical treatment and upgrade response

    Wider context from the report

    “(2) There appeared to be an opportunity shortly following the initial categorisation of the response, by a clinical floor walker, to upgrade to a code/categorisation which would likely have led to a swifter response, but an under-appreciation, or otherwise, of the then time critical treatment window open to the deceased. I was informed in evidence that the clinical floor walker would have had access to TOXBASE via the Clinical Support Desk at that time, & had that been accessed & information promptly secured regarding the treatment indicated, this would have alerted the clinician to the need for an acute emergency response. This was subsequently undertaken by the attending paramedic (albeit not via TOXBASE) some hours later, & who immediately after having accessed the treatments for massive ████████ overdose, appreciated that the deceased was a time sensitive patient & to convey to the emergency department with all haste. ”

    Source location

    Sarah Marie GILBERT-JONES · 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

    Use Clinical Support Desk flags to identify overdose incidents and enable faster or out-of-order vehicle allocation.

    Verbatim wording from the response

    “During the incident that was subject of the inquest, the floorwalker did upgrade the call to elicit a faster response, from an Amber 2 to an Amber 1. I wish to assure you that within the Standard Operating Procedure for the Clinical Support Desk, which allows clinicians to place a “flag” on an incident.”

    Source location

    2022-0037-Response-from-Welsh-Ambulance-Services-NHS-Trust_Published
    Page 2 · response
    Published 7 February 2022

    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

    Drug-specific overdose responses cannot be incorporated because drugs vary widely and prioritisation is based on current condition, not potential future deterioration.

    Verbatim wording from the response

    “The issues of investigating different actions for different drug types are twofold. There is the fact that the individual drugs that can be involved in overdose cases are many and varied. Additionally, this moves away from the basis of the Trust’s Clinical Response Model, where the sickest patients are identified and attended first. This Model is based on the patient’s condition at the time and is not based on potential future changes to their conditions.”

    Source location

    2022-0037-Response-from-Welsh-Ambulance-Services-NHS-Trust_Published
    Page 1 · response
    Published 7 February 2022

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Paul David Ryley · 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

    Paul David Ryley died at Birmingham Heartlands Hospital on 14 April 2018 from the effects of a paracetamol overdose and paracetamol-induced liver injury. After initially attending hospital, he re-presented with symptoms but routine blood tests were not undertaken and his symptoms were attributed to alcohol withdrawal. The principal concern was that guidance did not clearly address patients re-presenting after a paracetamol overdose, creating a risk that potentially life-saving treatment would not be given.

    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 Toxbase guidance for patients re-presenting after a paracetamol overdose

    Wider context from the report

    “1. The Toxbase Guidelines for Paracetamol overdose (which comprise of a general guidance sheet and then several sheets specific to the period since ingestion) were considered and it was identified that they do not expressly state whether or not they apply only to an initial attendance and do not set out any steps to be followed when a patient re-presents within a short time of an initial attendance for a Paracetamol overdose. 2. Evidence was heard from an ED Registrar, ED Consultant and the Consultant Hepatologist that lead the Trust’s root cause analysis investigation that the guidelines are commonly understood by emergency department practitioners within this Trust and elsewhere to be applicable only to the patient’s initial attendance and are therefore not considered when a patient re-attends even when that re-attendance is within days (in this case within 24 hours) of the initial attendance. Evidence from the experienced ED Consultant was that this is what he had understood from local and national training. 3. The evidence before the court was that it is, or ought to be, known that despite a plasma paracetamol level below the therapeutic threshold patients can go on to suffer liver toxicity following a paracetamol overdose and this is clearly stated within the Toxbase guidance. 4. In this case the clinicians did not refer to the Toxbase guidance when the Deceased represented other than to check that on his initial presentation his plasma paracetamol level had been below the therapeutic level (which it had been). 5. The evidence of a Consultant Hepatologist at the inquest was that he could not foresee any real risk in practice from following the guidance within the applicable Toxbase sheet based on time since ingestion even on a representation and to do so would in some cases result in treatment and avoid death. 6. There is therefore a risk that patients are not being given treatment that would increase their chances of survival because clinicians do not have clear guidance on what to do when a patient re-presents and do not regard the existing guidance as applicable. ”

    Source location

    Paul David Ryley · Prevention of Future Deaths report
    Page 1 · 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 apply Toxbase guidance when patients re-present after a paracetamol overdose

    Wider context from the report

    “1. The Toxbase Guidelines for Paracetamol overdose (which comprise of a general guidance sheet and then several sheets specific to the period since ingestion) were considered and it was identified that they do not expressly state whether or not they apply only to an initial attendance and do not set out any steps to be followed when a patient re-presents within a short time of an initial attendance for a Paracetamol overdose. 2. Evidence was heard from an ED Registrar, ED Consultant and the Consultant Hepatologist that lead the Trust’s root cause analysis investigation that the guidelines are commonly understood by emergency department practitioners within this Trust and elsewhere to be applicable only to the patient’s initial attendance and are therefore not considered when a patient re-attends even when that re-attendance is within days (in this case within 24 hours) of the initial attendance. Evidence from the experienced ED Consultant was that this is what he had understood from local and national training. 3. The evidence before the court was that it is, or ought to be, known that despite a plasma paracetamol level below the therapeutic threshold patients can go on to suffer liver toxicity following a paracetamol overdose and this is clearly stated within the Toxbase guidance. 4. In this case the clinicians did not refer to the Toxbase guidance when the Deceased represented other than to check that on his initial presentation his plasma paracetamol level had been below the therapeutic level (which it had been). 5. The evidence of a Consultant Hepatologist at the inquest was that he could not foresee any real risk in practice from following the guidance within the applicable Toxbase sheet based on time since ingestion even on a representation and to do so would in some cases result in treatment and avoid death. 6. There is therefore a risk that patients are not being given treatment that would increase their chances of survival because clinicians do not have clear guidance on what to do when a patient re-presents and do not regard the existing guidance as applicable. ”

    Source location

    Paul David Ryley · 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

    Add advice to the TOXBASE paracetamol index to manage patients who re-present after assessment and discharge as new presentations.

    Verbatim wording from the response

    “Nevertheless, in view of the coroner’s advice, we have added a further statement to the paracetamol index in our TOXBASE guidance as follows:”

    Source location

    2018-0284-Response-by-NPIS-Clinical-Standards-Group
    Page 1 · response
    Published 7 January 2019

    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

    TOXBASE guidance does not apply only to an initial presentation; it clearly covers different time intervals after paracetamol ingestion.

    Verbatim wording from the response

    “• Within this TOXBASE entry for patients greater than 24 hour after ingestion the advice clearly presented in point 2 is to check all bloods.”

    Source location

    2018-0284-Response-by-NPIS-Clinical-Standards-Group
    Page 1 · response
    Published 7 January 2019

    Open published response
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Data last updated 7 September 2026