Recurring concern

Unsafe medication administration

First to latest report 19 Sep 2013 — 19 Mar 2026

Reports that mention this concern
115
Times this concern has been raised
147
Stated actions linked to this concern
192

What this concern includes

Includes failures of controls dedicated to the end-to-end administration of prescribed medicines, including staff competence and supervision, administration accuracy and timing, monitoring, verification of ingestion, access and stock control, documentation, and follow-up of missed or incorrect doses.

What is not included
  • Excludes prescribing-only, medication-selection or clinical-review deficiencies where the concern is not tied to administration.
  • Excludes hazards involving counterfeit or unlawfully supplied medicines outside the administering organisation's medication-administration system.
  • Excludes generic record-keeping, staffing or training deficiencies that are not specifically dedicated to safe medication administration.
  • Excludes failures concerning unrelated information-sharing, assessment or care processes merely occurring in the same case.

Reports and published responses 115 reports

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

  1. Manchester South

    AI-generated summary

    Kenneth Edwards · 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

    Kenneth Edwards fell twice on 22 and 23 March 2025 and died on 23 March 2025 following traumatic subdural and subarachnoid haemorrhages. The principal concerns were that a subdural haematoma was missed on the first CT scan and that blood-thinning medication was administered while awaiting the results of a second CT scan to identify brain bleeding.

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    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 withhold blood-thinning medication while awaiting CT results for brain bleeding

    Wider context from the report

    “3. The administration of blood-thinning medication whilst awaiting the results of the second CT scan of the head to identify bleeding should not have happened. Whilst the treating clinician/s could not have known about the bleed that had not been identified on the first scan, they should have known that such medications were contra-indicated where the results of the second scan to identify brain bleeding were awaited. ”

    Source location

    Kenneth Edwards · Prevention of Future Deaths report
    Page 1 · concerns

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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 targeted education and training for emergency and acute care staff on anticoagulation risks, clinical vigilance and deferring treatment pending imaging.

    Verbatim wording from the response

    “This aspect of care has been subject to internal review and will be addressed through targeted education and training for emergency department and acute care staff. Specific emphasis will be placed on risk stratification, clinical vigilance, and the importance of deferring anticoagulation when intracranial pathology remains a possibility pending imaging confirmation.”

    Source location

    Response from Stockport NHS Foundation Trust
    Page 3 · response
    Published 13 August 2025

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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

    Complete an internal review of anticoagulation practice while intracranial pathology remains possible.

    Verbatim wording from the response

    “This aspect of care has been subject to internal review and will be addressed through targeted education and training for emergency department and acute care staff. Specific emphasis will be placed on risk stratification, clinical vigilance, and the importance of deferring anticoagulation when intracranial pathology remains a possibility pending imaging confirmation.”

    Source location

    Response from Stockport NHS Foundation Trust
    Page 3 · response
    Published 13 August 2025

    Open published response

  2. Oxfordshire

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    Cain Alex River Donald · 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

    Cain Alex River Donald died by hanging on 29 July 2022 after being discharged from Ashurst PICU directly into the community on 19 July 2022. The principal concerns were deficiencies in discharge planning and communication with his family and Probation Services, and failure by the Crisis Home Treatment Team to supervise medication administration and escalate concerns about compliance.

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    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 supervise medication taking as specifically instructed

    Wider context from the report

    “Post-discharge management of risk arising from medication compliance and multi-disciplinary team review. (3) Evidence suggested that during the period immediately prior to Mr Donald's death, staff of the CRHTT did not implement specific instructions to supervise Mr Donald taking his medication. By 24 July 2022, a decision had been made that Mr Donald should be supervised when taking his medication, but this direction was not adhered to in the following days. Escalation of this issue did not occur. There was no evidence of steps taken by the Trust since Mr Donald's death by way of training or guidance to CRHTT staff to address these issues. My conclusion was that had supervision and escalation taken place, it is possible this may have prevented a deterioration in Mr Donald's mental health which led to his death. ”

    Source location

    Cain Alex River Donald · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Review the CRHTT medications management process, standard operating procedure and staff orientation resources to clarify responsibilities and decision-making.

    Verbatim wording from the response

    “Lastly, the CRHTT is reviewing their medications management process in light of the inquest and your findings. The CRHTT clinical nurse lead is leading this work and met our Associate Director of Nursing in May 2025 in order to discuss your findings. The CRHTT has reviewed”

    Source location

    Response from Oxford Health NHS Foundation Trust
    Page 2 · response
    Published 17 June 2025

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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

    Develop a medications-management flowchart and assessment pro-forma to support administration-route decisions and efficacy assessment.

    Verbatim wording from the response

    “both its standard operating procedure and local staff orientation resources to ensure clarity regarding how and who is responsible for making decisions and undertaking actions in relation to all aspects of medications management. In summary, there are four broad scenarios for medications management: clinician administers medications, patient takes responsibility for self-administration of medications, a trusted person is involved, or prompting medications. The team has (since the inquest) developed two documents to assist with decision making and assessment of efficacy of medications. The first is a flow-chart directed at achieving the right route for each patient how medications are administered; the second is an assessment pro-forma to measure the efficacy of medications.”

    Source location

    Response from Oxford Health NHS Foundation Trust
    Page 3 · response
    Published 17 June 2025

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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

    Adopt the new medications-management flowchart and assessment pro-forma for use by the CRHTT.

    Verbatim wording from the response

    “both its standard operating procedure and local staff orientation resources to ensure clarity regarding how and who is responsible for making decisions and undertaking actions in relation to all aspects of medications management. In summary, there are four broad scenarios for medications management: clinician administers medications, patient takes responsibility for self-administration of medications, a trusted person is involved, or prompting medications. The team has (since the inquest) developed two documents to assist with decision making and assessment of efficacy of medications. The first is a flow-chart directed at achieving the right route for each patient how medications are administered; the second is an assessment pro-forma to measure the efficacy of medications.”

    Source location

    Response from Oxford Health NHS Foundation Trust
    Page 3 · response
    Published 17 June 2025

    Open published response

  3. Bedfordshire and Luton

    AI-generated summary

    Jacqueline GREEN · 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

    Jacqueline GREEN was admitted to Bedford Hospital after a fall and was found to be very weak, frail, cachectic and dehydrated. She received paracetamol at a dose intended for patients weighing over 50 kg despite weighing 33.6 kg, subsequently developed paracetamol-induced liver injury and died from liver failure. The concerns included inadequate safeguards for prescribing paracetamol to low-weight adults, unexplained variation in the administration of doses, and incomplete implementation of relevant safety measures.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Absence of medication-administration alerts for adults at risk of unintentional paracetamol overdose

    Wider context from the report

    “3. Despite the PSII report referencing the 2022 HSSIB report and recommending that this should be shared with staff, relevant Safety Observations made in the HSSIB Report appear to have been insufficiently addressed: (a) Although Bedford Hospitals NHS Trust are now using the Nevercentre electronic record system which, since 28th February 2024, has included the height and weight of patients and prevents a prescribing doctor from prescribing without a patient’s weight having first been entered, staff are still able to enter a estimated weight and there do not appear to be any alerts on this system to advise of the need for weight accuracy in the prescription of oral paracetamol and consideration of the risk of liver toxicity in those weighing under 50 kg (as advised in Safety Observation 02/2022/151); (b) Whilst the PSII report states as an Action that “Patients should be weighed on admission and the information documented”, other than the provision of a ‘pat slide’, no other practical actions are planned for actually achieving this outcome, particularly in respect of those adults at risk of an unintentional paracetamol overdose, such as an alert aimed at those administering medication as well as those prescribing it (as advised in Safety Observation 02/2022/151). ”

    Source location

    Jacqueline GREEN · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Add EPMA prescribing prompts requiring accurate weight recording and appropriate paracetamol dosing, including liver-toxicity warnings below 50 kilograms.

    Verbatim wording from the response

    “There is now a prompt when prescribing paracetamol (all routes) on EPMA that reminds prescribers of the need to ensure there is an accurate weight recorded and that the dose is appropriate.”

    Source location

    Response from Bedford Hospitals NHS Foundation Trust
    Page 3 · response
    Published 11 April 2025

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  4. Inner North London

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    Billie Diane WICKS · 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

    Billie Wicks, aged 16, was brought to hospital with an asthma attack and was discharged without adequate repeat observations or senior clinical review. The report states that her asthma was not diagnosed or treated and that she died from infective exacerbation of asthma. Concerns included understaffing and inadequate observations, delayed antibiotic treatment, lack of awareness of adult-onset asthma, and the limitations of safety-netting advice after her parents had already sought hospital care.

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    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 administer the first antibiotic dose in the emergency department

    Wider context from the report

    “2. The registrar who saw Billie the night before her death prescribed an antibiotic, but he was not in the habit of giving the first dose in the department and he did not on this occasion. This meant that Billie’s infection was not tackled as quickly as it could have been. This seems to indicate a training and potentially a guideline need. ”

    Source location

    Billie Diane WICKS · Prevention of Future Deaths report
    Page 2 · concerns

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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 mandatory induction and continuing teaching on paediatrics, deterioration, escalation, TTA medication use and individualized safety-netting.

    Verbatim wording from the response

    “• All new doctors starting in the Emergency Department, now receive a mandatory teaching session at induction focusing on paediatrics and paediatric deterioration and escalation with regular sessions timetabled ongoing to maintain this education.”

    Source location

    Response from Royal Free Hospitals
    Page 2 · response
    Published 17 March 2025

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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

    Progress plans for dedicated emergency-department pharmacy provision through the business-case approval process.

    Verbatim wording from the response

    “The addition of an ED pharmacist would support reliable stocking of medications, provide access to critical medications out of hours, education throughout the department and provide continuous and vital expertise. The lack of pharmacy resource within the Emergency Department is noted to be an area of concern. It is recognised and is continually monitored, risk mitigations have been identified, and actions are currently being driven to try to resolve this in the form of a business case. The business case is currently progressing through an approval process with a comprehensive action plan in place whilst this gap remains.”

    Source location

    Response from Royal Free Hospitals
    Page 3 · response
    Published 17 March 2025

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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

    Ensure sufficient adult TTA medication stock and assign medication-stock responsibilities in job planning.

    Verbatim wording from the response

    “This pharmacy resource has also been explored in greater detail in the Patient Safety Incident Investigation (PSII) and appropriate actions have been added to monitor progress of the business case previously referred to. An additional action to ensure there is sufficient supply of medication in the adult TTA stock cupboard in the Emergency Department and to include medication stock responsibilities in job planning has been agreed to further support the ED team in this area, this is being led by the Divisional Clinical Director for this area.”

    Source location

    Response from Royal Free Hospitals
    Page 3 · response
    Published 17 March 2025

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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

    Earlier antibiotics were unlikely to have altered Billie’s outcome because the infection was likely viral, although earlier treatment may benefit similar patients.

    Verbatim wording from the response

    “After a thorough review by the multidisciplinary team (MDT) panel, it was determined that antibiotics were unlikely to have altered the outcome, as the infection was likely to be viral in nature. The panel agreed that while initiating antibiotics at an earlier stage was unlikely to have altered the outcome for Billie, it may well alter the course of other patients in similar circumstances.”

    Source location

    Response from Royal Free Hospitals
    Page 3 · response
    Published 17 March 2025

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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

    No national guidance or clear rationale supports requiring clinicians to administer the first antibiotic dose absent suspected allergy.

    Verbatim wording from the response

    “Antibiotic administration It is good practice for the prescribing and administration of medicines to be performed by different practitioners [8]. There is current guidance on the management of sepsis. This would suggest that for sepsis without shock, antibiotics should be administered within three hours [9]. It is unclear whether Billie had sepsis. Guidance for the time to administer the first dose of antibiotics in people with infection without sepsis are less prescriptive. RCEM notes that Billie was discharged after about three and a half hours. It is assumed that she was given antibiotics at discharge, to self-administer. Antibiotics are only part of the management for an exacerbation of asthma thought to be secondary to a bacterial”

    Source location

    Response from Royal College of Emergency Medicine
    Page 1 · response
    Published 17 March 2025

    Open published response

  5. West Yorkshire (Western)

    AI-generated summary

    Raymond JENNINGS · 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

    Raymond JENNINGS, aged 84, was admitted to hospital with sepsis due to community-acquired pneumonia and died on 7 March 2023. His care home failed to promptly administer prescribed antibiotics or seek further medical advice when initial attempts to obtain them were unsuccessful. The report raised a concern that other vulnerable residents may be at future risk if prescribed medications are not administered promptly.

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    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 promptly administer prescribed medications

    Wider context from the report

    “Antibiotics for a chest infection were prescribed by Ray's out of hours GP on 16.02.23. The care home made initial attempts to obtain the antibiotics from a pharmacy that evening but failed to achieve this. They did not seek further medical advice or admission to hospital that night. Further unsuccessful attempts were made to obtain the antibiotics the next day. No attempts were made to obtain antibiotics on 18.02.23 nor was further medical advice or admission to hospital sought. By 19.02.23 Ray's condition had deteriorated to the extent that he required hospital admission. Despite appropriate treatment in hospital, Ray did not recover and he died on 07.03.23. The medical evidence was clear that, although it could not be said that prompt admission of antibiotics would have probably prevented the need for Ray to be admitted to hospital and/or his death, the failure to either promptly administer the antibiotics or seek further medical care for him was a significant failing on the part of the care home. This was admitted in evidence and was identified as a missed opportunity. Evidence was given by the care home that lessons had been learned and systems improved but no documents were adduced in support of this such that the court could be confident that this issue would not reoccur. For that reason this report is being issued, in particular in relation to the concern that there may be a future risk that other vulnerable residents may not have their need for the prompt administration of prescribed medications met. ”

    Source location

    Raymond JENNINGS · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Update the medication policy to require medical advice when emergency medication is unavailable for three hours.

    Verbatim wording from the response

    “We have updated our medication policy which has been reviewed and sent to be signed by all staff. This states that should a out of hours/emergency medication be prescribed and is either out of stock or unobtainable within 3 hours the team are to call for medical advice.”

    Source location

    Response from Abbey Place Nursing Home
    Page 1 · response
    Published 7 March 2025

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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

    Implement an electronic medication system providing daily management oversight of stock levels, missed medicines and other medication issues.

    Verbatim wording from the response

    “We have implemented an electronic medication system throughout the home, this system emails a report daily to the home management and area manager with stock levels, missed medications or any other medication issues so they can have complete oversight.”

    Source location

    Response from Abbey Place Nursing Home
    Page 1 · response
    Published 7 March 2025

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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

    Move all residents to the same GP surgery and pharmacy to improve communication and medication processes.

    Verbatim wording from the response

    “We have changed so that all residents use the same GP surgery and pharmacy, this allows clear communication between the home and the designated organisations and builds a close relationship with them which has significantly improved the medication processes throughout the home.”

    Source location

    Response from Abbey Place Nursing Home
    Page 1 · response
    Published 7 March 2025

    Open published response

  6. Northamptonshire

    AI-generated summary

    Mr Leslie Hurwood · 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 Leslie Hurwood died on 13 January 2023 at Kettering General Hospital, having had a history of Type I diabetes and other health conditions, and a recent diagnosis of dementia. During a December 2022 admission after a fall, he experienced multiple episodes of hypoglycaemia. The report raises concerns that nurses at Northampton General Hospital administered insulin after meals rather than before them, and that this practice continued to occur occasionally despite advice and training.

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    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 insulin-administration training to reach all nurses

    Wider context from the report

    “In December 2022 Mr Hurwood was an in-patient at Northampton General Hospital. This followed a fall at home. During this admission he suffered multiple episodes of hypoglycaemia. Mr Hurwood’s insulin medication was to be provided by nurses within the hospital. I have heard evidence from a Diabetes Specialist Nurse at the Diabetes Centre at Northampton General Hospital that on 12 December 2022 Mr Hurwood was referred by ward staff for a diabetes review. The Diabetes Specialist Nurse explained in evidence that she observed that nurses (plural) were administering Mr Hurwood’s insulin after meals. She advised the nurses that Mr Hurwood’s insulin should be provided before his meals. In evidence, the Diabetes Specialist Nurse told me: a. Insulin should be administered prior eating. b. Its effectiveness is reduced if not administered before eating. c. This was not the only time that she was aware that nurses at Northampton General Hospital were (incorrectly) administering insulin to patients after they had eaten their meals. d. This continues to happen “occasionally”: the most recent episode which she had directly encountered occurred in the last 2 to 3 months. e. Whilst the Diabetes Centre members have had discussions with nurses and training does occur “the message does get through for some people”. The implication – which she agreed was the correct implication – was that the “message” did not get through to other nurses. A former Ward Sister at Northampton General Hospital has also given evidence at the inquest. She agreed that staff must get insulin administration correct. She thought the incorrect administration of insulin after a meal “probably does happen”. She accepted that there was “no excuse” for this, but pointed to the possible contributory effect of a lack of staff. ”

    Source location

    Mr Leslie Hurwood · Prevention of Future Deaths report
    Page 1 · concerns

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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 administer insulin before meals

    Wider context from the report

    “In December 2022 Mr Hurwood was an in-patient at Northampton General Hospital. This followed a fall at home. During this admission he suffered multiple episodes of hypoglycaemia. Mr Hurwood’s insulin medication was to be provided by nurses within the hospital. I have heard evidence from a Diabetes Specialist Nurse at the Diabetes Centre at Northampton General Hospital that on 12 December 2022 Mr Hurwood was referred by ward staff for a diabetes review. The Diabetes Specialist Nurse explained in evidence that she observed that nurses (plural) were administering Mr Hurwood’s insulin after meals. She advised the nurses that Mr Hurwood’s insulin should be provided before his meals. In evidence, the Diabetes Specialist Nurse told me: a. Insulin should be administered prior eating. b. Its effectiveness is reduced if not administered before eating. c. This was not the only time that she was aware that nurses at Northampton General Hospital were (incorrectly) administering insulin to patients after they had eaten their meals. d. This continues to happen “occasionally”: the most recent episode which she had directly encountered occurred in the last 2 to 3 months. e. Whilst the Diabetes Centre members have had discussions with nurses and training does occur “the message does get through for some people”. The implication – which she agreed was the correct implication – was that the “message” did not get through to other nurses. A former Ward Sister at Northampton General Hospital has also given evidence at the inquest. She agreed that staff must get insulin administration correct. She thought the incorrect administration of insulin after a meal “probably does happen”. She accepted that there was “no excuse” for this, but pointed to the possible contributory effect of a lack of staff. ”

    Source location

    Mr Leslie Hurwood · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Essex

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    MARY MARGARET WHITLOCK · 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 Margaret Whitlock died at Broomfield Hospital on 23 August 2023 after sustaining cervical fractures in a fall and subsequently suffering aspiration following assisted feeding while experiencing swallowing difficulties. The report identified concerns about delayed provision of a recommended collar, inadequate planning and communication regarding swallowing and oral intake, medication administration despite recorded opioid allergies, understaffing, and the absence of discharge and safety-netting advice to her care home.

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    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 prevent administration of morphine to patients with recorded opioid allergies

    Wider context from the report

    “(1) Morphine in the form of 5mg Oramorph and then 2.5mg Intravenous morphine was administered for a patient where the medication record noted allergy to Tramadol, Codeine and Buprenorphine. Naloxone was required to reverse the effect. Whilst this did not cause or contribute to this death this matter was not part of the Trust review, and no safeguards was raised. ”

    Source location

    MARY MARGARET WHITLOCK · 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

    Share learning from the opioid analgesia incident with Emergency Department colleagues to inform future practice.

    Verbatim wording from the response

    “In retrospect, the clinicians consider that a smaller dose than 2.5mg, of 1mg increments of opiate would have been more appropriate given her noted allergies. Learning from this case has been shared with Emergency Department colleagues accordingly for future practise.”

    Source location

    Response from Mid & South Essex NHS Trust
    Page 2 · response
    Published 19 December 2024

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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

    Opioid analgesia was within acceptable clinical decision-making, so further review or safeguarding was not considered necessary.

    Verbatim wording from the response

    “The choice of analgesia was not included as a term of reference for our review as it was within an acceptable range of clinical decision making, and a safeguarding was not triggered or indicated for this event. The use of opioid analgesia was made on a balance of risk basis and the risks of allergy were carefully managed.”

    Source location

    Response from Mid & South Essex NHS Trust
    Page 2 · response
    Published 19 December 2024

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  8. Surrey

    AI-generated summary

    Peter McCarthy · 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

    Peter McCarthy fell from his wheelchair at home on 25 November 2023, was found the following morning, and was taken to hospital with rib fractures and a subdural hematoma. He deteriorated and died on 30 November 2023 from heart failure and pneumonia. The principal concern was the absence of a protocol governing whether anticoagulant medication should be given to a client after a fall without medical oversight.

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    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 a protocol for medication oversight after client falls

    Wider context from the report

    “Following the inquest Care 4 U have put in place steps to ensure staff do not leave clients alone whilst they wait for ambulances. However, I remain concerned that: 1. On her arrival the carer offered Mr McCarthy his daily medications, which included an anticoagulant. He refused to take it. Following the conclusion of the inquest I sought information from Care4U Healthcare as to what, if any, protocol they have to ensure that clients who have fallen are not given anticoagulant medication without medical oversight. I have been told that medication comes in blister packs and the staff would not know if any medication was contra indicated after a fall. To date no protocol has been provided to the Court to deal with this type of situation. ”

    Source location

    Peter McCarthy · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. West Yorkshire Eastern

    AI-generated summary

    Amanda Richardson · 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

    Amanda Richardson, aged 40, was transferred from prison to a low secure mental health hospital and was found dead in her bedroom on 29 April 2023. Toxicology found a very high level of a prescribed drug, which had been prescribed at double the stipulated maximum dose, alongside evidence of illicit drug use. The concerns included inadequate medication review and monitoring, failures to record and investigate searches, and the adequacy of hospital security arrangements.

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    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 hospital systems to review and safeguard medication prescribing and administration

    Wider context from the report

    “2. It was admitted that the prescription of ████████ at the rate of ████████mg/day was double the ████████mg/day stipulated maximum (without additional monitoring being undertaken) and was made in error. This situation went unnoticed for some six months, until her death. There was no effective system of review in the hospital in this period. The pharmacist appears to have dispensed the drug without querying the high dose. The nurses who administered the drugs did not question it. The MDT meetings which took place did not check the dose, or reflect upon its potential interaction with the several other medications prescribed. Overall, there was no effective resilience in the hospital’s systems to safeguard against drugs bring prescribed or administered in error. ”

    Source location

    Amanda Richardson · Prevention of Future Deaths report
    Page 1 · concerns

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    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

    Actions taken following the Serious Incident Report are considered sufficient to address identified issues and prevent similar future deaths.

    Verbatim wording from the response

    “Inmind Healthcare remain committed to learning and improving service but given the assurances given to the Coroner at the Inquest, Inmind Healthcare consider that actions have been taken to fully address the issues identified by the Serious Incident Report and to prevent future deaths in similar circumstances.”

    Source location

    Response from InMind
    Page 2 · response
    Published 10 September 2024

    Open published response

  10. Cambridgeshire and Peterborough

    AI-generated summary

    Rachel Gibson · 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

    Rachel Gibson underwent hip replacement surgery in April 2022 and received an excessive dose of Ropivacaine, after which she suffered an unwitnessed cardiac arrest and irreversible brain damage. She died in hospital on 14 July 2022. The principal concerns were unclear responsibilities for prescribing, checking and administering the local anaesthetic, inconsistent prescription units, and wide variation in similar practices nationally.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Variation in local anaesthetic administration practices

    Wider context from the report

    “1. The responsibility for checking and administering the local anaesthetic is unclear: 1. The instruction was given orally and not written down by the anaesthetist (the prescriber). 2. The anaesthetist did not check what the nurse had written down. 3. The nurse drew up the local anaesthetic from a stock bag and checked this with another nurse, but not with the anaesthetist. 4. The nurse then handed the drawn-up anaesthetic to the surgeon to administer. 2. There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced. 3. The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation. However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation. This is why I believe I am under a duty to draw it to your attention. ”

    Source location

    Rachel Gibson · 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

    Unclear responsibility for administering the local anaesthetic

    Wider context from the report

    “1. The responsibility for checking and administering the local anaesthetic is unclear: 1. The instruction was given orally and not written down by the anaesthetist (the prescriber). 2. The anaesthetist did not check what the nurse had written down. 3. The nurse drew up the local anaesthetic from a stock bag and checked this with another nurse, but not with the anaesthetist. 4. The nurse then handed the drawn-up anaesthetic to the surgeon to administer. 2. There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced. 3. The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation. However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation. This is why I believe I am under a duty to draw it to your attention. ”

    Source location

    Rachel Gibson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026