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

    Jane Elizabeth Wadsworth · 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

    Jane Elizabeth Wadsworth became seriously unwell after elective hip surgery, developing a deep vein thrombosis, cellulitis, sepsis, acute kidney injury and liver failure, and died on 31 December 2022 despite intensive care treatment. Concerns included missed antibiotic doses, limited consultant input, unclear escalation and doctor-to-doctor discussion about intensive care, unavailable Critical Care Outreach support, and no evidence that specialist liver advice was obtained.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure administration and escalation of missed antibiotic doses

    Wider context from the report

    “1. Mrs Wadsworth missed three doses of antibiotics prescribed to treat her infection according to the evidence given to the inquest. This did not appear to have been escalated and there was no clear explanation regarding this occurring other than that her cannula may not have been in place and there was a delay in a doctor being available to reinsert one; ”

    Source location

    Jane Elizabeth Wadsworth · Prevention of Future Deaths report
    Page 3 · 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

    Audit omitted medication doses through pharmacy, ward quality-assurance and accreditation processes, reporting results and sharing learning for improvement.

    Verbatim wording from the response

    “The Trust continue to focus on improvement in relation to missed doses of medication. There is an established program of medication audits which are reported to the Trust’s Medication Safety Group. The Medication Group meet bi-monthly and has a multidisciplinary membership. At present the Pharmacy Department perform an annual snapshot retrospective audit which focuses on omitted/unsigned doses. The audit covers inpatient areas and looks at any medication doses which are not administered as prescribed and the documented reasons for this. The most recent audit was presented to Trust Medicines Safety Group on 28/04/23.”

    Source location

    Response from Tameside and Glossop Integrated Care
    Page 2 · response
    Published 21 July 2023

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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

    Issue a staff poster explaining how to prevent medication omissions and obtain unavailable medicines.

    Verbatim wording from the response

    “The Trust recognise that there is an overall percentage of medication doses which are omitted for a ‘non-valid clinical reason’. This means that unsigned doses would be recorded under this category (along with any medication doses omitted due to lack of availability). In the last completed audit the percentage of medication doses omitted for a ‘non-valid clinical reason’ averaged 4% of all prescribed doses. This audit is part of the Trust’s standard audit cycle and the results are fed back to the multidisciplinary Medicines Safety Group. One of the actions from the last audit was to issue a new poster which highlights to all staff how to avoid omissions in medication- this includes information of how to access medication if unavailable within the clinical area.”

    Source location

    Response from Tameside and Glossop Integrated Care
    Page 2 · response
    Published 21 July 2023

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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

    Redesign the medication kardex to highlight time-critical medicines and streamline ward medication-ordering and emergency supply arrangements.

    Verbatim wording from the response

    “The Trust medication kardex has been redesigned to place greater emphasis on time critical medications. Pharmacy systems for ordering medications to the ward have been streamlined and the Trust also has an emergency medication cupboard and an on-call pharmacy for obtaining medications out of hours. I attach a copy of the template of the updated medicines kardex and the PowerPoint slides to support the new medicine chart for your consideration and information.”

    Source location

    Response from Tameside and Glossop Integrated Care
    Page 3 · response
    Published 21 July 2023

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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 each ward with an allocated pharmacist and pharmacy technician to review treatment sheets daily and support timely medication ordering.

    Verbatim wording from the response

    “To provide further support for inpatient areas each ward has a Ward based Pharmacy Team. Each ward area has an allocated ward pharmacist and pharmacy technician who evaluate individual treatment sheets on a daily basis. They form a key element of the multidisciplinary team caring for our patients. Pharmacy presence on the wards supports the accurate prescribing and administration of medication. They also ensure timely ordering of medications which do not form part of the routine medication stocked within the ward area.”

    Source location

    Response from Tameside and Glossop Integrated Care
    Page 3 · response
    Published 21 July 2023

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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 medication-omission induction and refresher training, with medication-management assessment for nurses new to the Trust.

    Verbatim wording from the response

    “The issue of omitted doses is covered in the nursing induction training that the Pharmacist delivers. Every nurse receives this training at the point of joining the Trust. This training can also be accessed as a refresher course. Every nurse new to the Trust also receives a medication management assessment undertaken by the Ward Manager which evidences safer practice in keeping with Trust policy. This is recorded in the individual’s personnel file and a copy sent to the learning and development department.”

    Source location

    Response from Tameside and Glossop Integrated Care
    Page 3 · response
    Published 21 July 2023

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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

    The concerns fall under the Trust’s remit rather than NHS England’s functions.

    Verbatim wording from the response

    “The matters of concern raised in your Report come under the remit of Tameside and Glossop Integrated Care NHS Foundation Trust (hereafter “the Trust”), who are therefore the appropriate organisation to respond to the concerns raised. I am however grateful to you for bringing these important patient safety issues to my attention. The concerns have been shared with my relevant regional Quality colleagues in the North West, who are engaging with Greater Manchester Integrated Care Board (the responsible commissioning body for Greater Manchester) about the issues raised.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 21 July 2023

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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

    The Trust is the appropriate organisation to respond, with the Greater Manchester Integrated Care Board responsible for commissioning.

    Verbatim wording from the response

    “The matters of concern raised in your Report come under the remit of Tameside and Glossop Integrated Care NHS Foundation Trust (hereafter “the Trust”), who are therefore the appropriate organisation to respond to the concerns raised. I am however grateful to you for bringing these important patient safety issues to my attention. The concerns have been shared with my relevant regional Quality colleagues in the North West, who are engaging with Greater Manchester Integrated Care Board (the responsible commissioning body for Greater Manchester) about the issues raised.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 21 July 2023

    Open published response

  2. East London

    AI-generated summary

    Mr John Michael James · 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 John Michael James was admitted to hospital with malnutrition and a bowel obstruction caused by an adenocarcinoma, and later underwent surgery and intensive care. He died from a pulmonary embolism after three missed doses of prescribed anticoagulation medication; the report raised concern that the refusals were not escalated and that there was no electronic alert to notify medical staff when doses were not administered.

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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 electronic alerts escalating non-administration of prescribed anticoagulation medication to the medical team

    Wider context from the report

    “The refusal of anti-coagulation medication was not brought to the attention of medical staff. The administration of anti-coagulation medication to patients like Mr James, is vital for reducing the risk of a venous thrombo-embolism, a potentially life-threatening condition. There is no electronic prompt/alert to highlight to the medical team when prescribed anticoagulation medication is not administered. The Trust’s internal investigator recognised that a fail-safe should be put in place within the electronic records, to ensure escalation to the medical team where doses of prescribed anti-coagulation are not administered. Such a measure could prevent similar deaths from occurring. It was considered that this measure could assist in preventing future deaths not just locally, but at a wider level. ”

    Source location

    Mr John Michael James · 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

    Update Millennium training so multidisciplinary teams understand and use visual flags to prevent omission of critical medications.

    Verbatim wording from the response

    “Our response: The electronic prescribing and medicines administration system (ePMA) currently has functionality (all of which is accessible via Millennium®) to reduce harm associated with missed or late medication administration. This includes visual aids in the form of a red tile if a dose is delayed by more than 2 hours. This visual flag is available to all users. Millennium training will be updated to reflect learning from this case to ensure that multi-professional teams know how to use the flag system to ensure critical medications are not omitted.”

    Source location

    Response from Bart Health NHS Trust
    Page 2 · response
    Published 18 July 2023

    Open published response

  3. Cornwall and Isles of Scilly

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    JOHN ALFRED ROBERTS · 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

    John Alfred Roberts, aged 78, was admitted with vomiting and retching and was found to have an inoperable perforated sigmoid colon. He was discharged home for palliative care and died there on 26 June 2021. The substantive concerns related to an inadvertent reduction in his prednisolone dosage at Royal Cornwall Hospital and the adequacy of medication-error arrangements, as well as omissions in NICE’s BNF guidance about the risk of bowel perforation associated with corticosteroids in people with diverticular disease.

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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 prescribed steroid dosage accurately

    Wider context from the report

    “(1) Royal Cornwall Hospital (RCHT) • The concern is the inadvertent reduction of steroid dosage and the arrangements made in relation to the administration of medication dosages and the policies regarding dosage errors, and the application of those policies. • The Court heard that the dosage of 100mg prednisolone was inadvertently reduced to 25mg from 7 to 13 June. The full dose of 100mg was given either side of that period, on 5 and 15 June 2021. No explanation was offered for this reduction other than it being an inadvertent mistake. • RCHT Consultants accepted that the dosage error was a serious mistake. Furthermore, this mistake was not drawn to the patient John’s attention or to the attention of the GP via the discharge summary, which made no reference to the dosage error. It was unclear whether treating physicians or discharging physicians were aware of the dosage error. (2) The National Institute for Clinical Excellence (NICE) • The concern is regarding the accuracy and rigour of the British National Formulary (BNF) guidance on Prednisolone, published by NICE, The National Institute for Clinical Excellence • BNF provides Key information on the selection, prescribing, dispensing and administration of medicines. The BNF aims to provide prescribers, pharmacists, and other healthcare professionals with sound up-to-date information about the use of medicines. • Evidence was taken at Inquest from a consultant neurologist that recent literature suggests an association between steroids (such as prednisolone) and the risk of bowel perforation in those with diverticular disease. This is not reflected in the BNF guidance regarding prednisolone. • In relation to a number of sections in the Prednisolone guidance it was found as follows • The ‘Important safety information’ section does not refer to the risk of perforation from using corticosteroids for those with diverticular disease • The ‘Contra-indications For all corticosteroids (systemic)’ section does not refer to need for caution in using corticosteroids for those with diverticular disease, albeit it does refer to caution in using with patients with diabetes mellitus and diverticulitis • The ‘Side effects’ section makes no reference to bowel perforation as a risk, albeit it does make reference to peptic ulceration. ”

    Source location

    JOHN ALFRED ROBERTS · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Sefton, St Helens and Knowsley

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    Beryl ELLISON · 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

    Beryl Ellison was receiving end-of-life care at Alexandra Care Home and was found deceased there on 28 June 2022. The inquest concluded that her death resulted from underlying poor health in combination with taking an excessive quantity of prescribed medication. Concerns included unsupervised access to syringe medication, prior family reports about medication being left in her room, and the absence of an explanation for the excessive oxycodone concentration found after her death.

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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 syringe medication

    Wider context from the report

    “Mrs Ellison was resident at Alexandra Care Home and was found deceased on 28th June 2022 by staff. Her family expressed concern that she had been left with syringe medication unsupervised by staff and raised concerns about this with the care home both historically and four days prior to her death. A post mortem examination revealed Mrs Ellison to have an excessive concentration of oxycodone in her system which was likely to exceed any acquired tolerance level. The evidence heard at inquest revealed no explanation as to why Mrs Ellison was found to have taken the excessive quantity of oxycodone which contributed to her death. Furthermore, the systems at the care home were stated categorically to be the same as those that were in place prior to Mrs Ellison's death. ”

    Source location

    Beryl ELLISON · 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

    Conduct weekly observations of medicine rounds.

    Verbatim wording from the response

    “• Weekly observations of drug rounds are now completed.”

    Source location

    Response from Four Seasons Health Care Group
    Page 1 · response
    Published 9 January 2023

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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

    Write and share a specific medication risk assessment when medication-management risk is identified, retaining it with medication records.

    Verbatim wording from the response

    “Where a risk to medication administration or management is identified for any resident, a specific medication risk assessment will be written and shared with the nursing and care team to ensure awareness of the specific risk and control measures in place. For ease of reference and to ensure that this potential risk is highlighted at each drug round to the member of staff administering medication, a copy of this risk assessment will be held alongside the medication administration records for the individual resident.”

    Source location

    Response from Four Seasons Health Care Group
    Page 4 · response
    Published 9 January 2023

    Open published response

  5. Norfolk

    AI-generated summary

    Janice HOPPER · 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

    Janice HOPPER was discharged from hospital to a care home on 31 December 2021, became unwell in January 2022, was admitted to hospital, and died on 12 February 2022. Concerns included inaccurate and inadequately reviewed care plans, failures to monitor blood glucose, food and fluid intake, and the administration of Morphine Sulphate as a matter of course despite instructions that it was to be given only as required. The inquest recorded the medical cause of death as Alzheimer's Dementia, Chronic Kidney Disease and Type 2 Diabetes Mellitus, with a conclusion of natural causes.

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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 as-needed morphine only when required

    Wider context from the report

    “10. Mrs Hopper was discharged from hospital with medication including Morphine Sulphate. The written instructions were she was to be given a dose four times a day "as and when required". Mrs Hopper was given seventeen doses of Morphine Sulphate as a matter of course, regardless of whether this was required, before this was stopped by a General Practitioner. ”

    Source location

    Janice HOPPER · 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 person-centred protocols and care-plan instructions for PRN medicines, including pain assessment for residents unable to verbalise pain.

    Verbatim wording from the response

    “All as required (PRN) medication has a protocol produced that is person centred. For any resident that has a cognitive impairment and is unable to verbalise pain, staff will assess whether they are or are not in pain by using facial expressions, body language or a pain assessment tool to gain this information and act on the information obtained.”

    Source location

    Response from Runwood Homes
    Page 2 · response
    Published 1 December 2022

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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 additional medication training to senior care staff to develop their medication-administration skills.

    Verbatim wording from the response

    “PRN medications are documented in the residents care plan, along with regular medication, so all senior staff that are medication trained will have this knowledge when administering medication, all senior staff have been completing extra medication training to develop their skills.”

    Source location

    Response from Runwood Homes
    Page 2 · response
    Published 1 December 2022

    Open published response

  6. Norfolk

    AI-generated summary

    Bonnie Rose WEBSTER · 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

    Bonnie Rose Webster was born by emergency caesarean section in a poor condition on 9 February 2022, required resuscitation and neonatal treatment, and died the following day after her condition deteriorated. Concerns included communication with her parents about the seriousness of the situation, a delay in giving prescribed antibiotics, and paediatric staff being alerted on foot rather than through the emergency bleep system.

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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

    Delays in administering prescribed antibiotics

    Wider context from the report

    “2. Antibiotics were prescribed at the initial review meeting at 09.35 hours. These were not given until 12.30 hours ”

    Source location

    Bonnie Rose WEBSTER · 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

    Develop and deliver an SBAR handover training programme for all neonatal intensive care nursing and medical staff.

    Verbatim wording from the response

    “This point has been thoroughly investigated and all staff involved have received a debrief. It was found that whilst some staff were aware the prescription had been written, this was not communicated to, or handed over to the nurse directly caring for Bonnie. We are currently using the facts of this case and learning from the incident to assist in a new training programme for all Neonatal Intensive Care Unit (NICU) staff, both nursing and medical, to ensure clear and concise handover of information using the SBAR approach (Situation-Background-Assessment-Recommendation).”

    Source location

    Response from The Queen Elizabeth Hospital King's Lynn
    Page 2 · response
    Published 25 November 2022

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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

    Debrief staff involved in the delayed antibiotic communication.

    Verbatim wording from the response

    “This point has been thoroughly investigated and all staff involved have received a debrief. It was found that whilst some staff were aware the prescription had been written, this was not communicated to, or handed over to the nurse directly caring for Bonnie. We are currently using the facts of this case and learning from the incident to assist in a new training programme for all Neonatal Intensive Care Unit (NICU) staff, both nursing and medical, to ensure clear and concise handover of information using the SBAR approach (Situation-Background-Assessment-Recommendation).”

    Source location

    Response from The Queen Elizabeth Hospital King's Lynn
    Page 2 · response
    Published 25 November 2022

    Open published response

  7. East London

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    Ghulam Mohammad · 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

    Ghulam Mohammad, an 89-year-old man, was admitted to hospital after an unwitnessed fall and later sustained a head injury in a further hospital fall. His CT head was delayed for four days, and enoxaparin was prescribed and administered before the extent of any intracranial injury was known. The report also identifies inadequate record keeping and omissions in the initial investigation and consultant statement concerning the use of enoxaparin.

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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 assess intracranial damage before prescribing and administering enoxaparin

    Wider context from the report

    “3. Before the requested CT head was undertaken, a doctor prescribed blood thinning medication – enoxaparin to Mr Mohammed. Enoxaparin can exacerbate an intra-cranial bleed. The medication was administered on 13 & 14th October 2021. Both the prescription and the administrations of enoxaparin were made without knowing the extent of any intra-cranial damage caused by the fall on 11/10/21. ”

    Source location

    Ghulam Mohammad · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. East London

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    Michael John Vince · 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

    Michael John Vince, a patient of the community mental health team receiving treatment for schizo-affective disorder, was found deceased at home on 19 June 2021 after apparently taking an overdose. The concerns included prolonged prescribing of medication for insomnia, lack of meaningful prescription review, failure to share evidence of dependence, and failure to monitor the frequency of PRN administration.

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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 monitor the frequency of PRN medication administration

    Wider context from the report

    “4. The frequency with which Mr Vince was administering his PRN ████████ was never monitored. ”

    Source location

    Michael John Vince · 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

    Update medication-monitoring practice and jointly monitor its implementation with the chief pharmacist.

    Verbatim wording from the response

    “The current practice at NELFT is that whoever prescribes the medication, is responsible for monitoring the compliance with medication administration regime. However, in light of learning from this inquest we have updated our practice as highlighted within the attached action plan and will monitor implementation of the updated practice jointly with the chief pharmacist.”

    Source location

    Response from North East London Foundation Trust
    Page 2 · response
    Published 23 September 2022

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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

    Audit and clinically review all patients prescribed Zopiclone over the previous two years, including structured reviews and a second-cycle review of repeat prescriptions.

    Verbatim wording from the response

    “A. Clinical Audit of all patients prescribed Zopiclone over the past 2 years:”

    Source location

    Response from High St Surgery
    Page 2 · response
    Published 23 September 2022

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  9. Gwent

    AI-generated summary

    Ian Anthony Charles Miller · 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

    Ian Anthony Charles Miller was serving a term at HMP Usk and died by suicide in the prison on 21 September 2019 after being told he could not live at the family home or with his father-in-law, could not have unsupervised contact with his children, and might be homeless. The report raised concerns that prisoners were trading prescribed medication at HMP Usk and that unprescribed medication was being ingested, putting other prisoners’ lives at risk.

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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 secure and control prisoners’ prescribed medication

    Wider context from the report

    “1. The management of medication prescribed to prisoners. At post mortem examination the toxicologist determined that there were a number of drugs in Ian’s blood and urine that he had not been prescribed. The court was informed that at HMP Usk, all prisoners are required to be capable of managing their own medication. The medications are not kept in a locked facility. The evidence provided clearly indicated that prisoners were trading prescribed medication which had become a form of currency within the prison. Ian’s former cellmate indicated this practice was rife and indeed Ian bought medication from other prisoners. Evidence was heard from the Governor / Head of Safety at HMP Usk who informed the court that he was not aware of this practice, and it appears this was also not known by the prison officers. The court was informed that there is a system of randomised checks in place within the prison to attempt to determine whether prisoners are appropriately managing their medication, however prisoners have clearly found ways around this. Whilst the ingestion of unprescribed medication did not contribute to Ian’s death, this practice, if left unchecked, clearly puts the lives of other prisoners at risk in the future. ”

    Source location

    Ian Anthony Charles Miller · 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

    Issue staff guidance on detecting, recording and reporting prescribed-medication trading.

    Verbatim wording from the response

    “In order to ensure that staff are aware of this issue and the risk that prisoners trading prescribed medications presents, the Deputy Governor issued guidance to staff in January 2022 highlighting what they must look out for, and the importance of recording any instances of this immediately including informing the healthcare provider. This notice will be re-issued annually to continually raise staff awareness and ensure that new staff are also informed.”

    Source location

    2022-0001-Response-from-HMPPS_Published
    Page 1 · response
    Published 10 January 2022

    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

    Reissue medication-trading guidance annually to maintain staff awareness and inform new staff.

    Verbatim wording from the response

    “In order to ensure that staff are aware of this issue and the risk that prisoners trading prescribed medications presents, the Deputy Governor issued guidance to staff in January 2022 highlighting what they must look out for, and the importance of recording any instances of this immediately including informing the healthcare provider. This notice will be re-issued annually to continually raise staff awareness and ensure that new staff are also informed.”

    Source location

    2022-0001-Response-from-HMPPS_Published
    Page 1 · response
    Published 10 January 2022

    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

    Monitor and collate medication-trading intelligence for consideration at weekly staff security briefings.

    Verbatim wording from the response

    “Any intelligence received about instances of prisoners trading medication will continue to be monitored and collated by the security department and considered during the weekly staff security briefings to ensure that all staff are aware of emerging trends and risks.”

    Source location

    2022-0001-Response-from-HMPPS_Published
    Page 1 · response
    Published 10 January 2022

    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

    Apply detailed security risk assessments to prisoners working in the recycling department.

    Verbatim wording from the response

    “Increased measures have been introduced in areas of high risk across the prison, this includes the recycling department which now has more detailed security risk assessments for all prisoners that work there, due to them potentially coming into contact with discarded medications. Amnesty bins have also been added to the wings to ensure that medications may be disposed of correctly, when required.”

    Source location

    2022-0001-Response-from-HMPPS_Published
    Page 2 · response
    Published 10 January 2022

    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

    Install amnesty bins on prison wings for correct disposal of medications.

    Verbatim wording from the response

    “Increased measures have been introduced in areas of high risk across the prison, this includes the recycling department which now has more detailed security risk assessments for all prisoners that work there, due to them potentially coming into contact with discarded medications. Amnesty bins have also been added to the wings to ensure that medications may be disposed of correctly, when required.”

    Source location

    2022-0001-Response-from-HMPPS_Published
    Page 2 · response
    Published 10 January 2022

    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

    Conduct monthly random medication checks covering 10% of the prison population and address discrepancies through medication reviews.

    Verbatim wording from the response

    “Random medication checks have been increased to 10% of the prison population and are conducted monthly by both healthcare and prison staff. The checks are to ensure that a prisoner has the correct in-possession medication in the right quantities and any discrepancies are immediately addressed through medication reviews.”

    Source location

    2022-0001-Response-from-HMPPS_Published
    Page 2 · response
    Published 10 January 2022

    Open published response

  10. Berkshire

    AI-generated summary

    Saif Mubeen Hussain · 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

    Saif Mubeen Hussain died at John Radcliffe Hospital on 10 June 2021 after being admitted following an incident in Bracknell, Berkshire, on 3 June 2021; the recorded cause of death was polytrauma. During his transfer between units, he was administered a Heparin infusion at almost eight times the prescribed rate. The report identified concerns about unfamiliarity with anticoagulants, inadequate double-checking, the Guardrails system being switched off, differences between prescription and administration rates not being flagged, and the use of separate hospital computer systems.

    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 appropriate limits on the administration of certain drugs

    Wider context from the report

    “2. How the system could incorporate appropriate limits on the administration of certain drugs within that system. ”

    Source location

    Saif Mubeen Hussain · 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

    Implement dose-error-reduction infusion pumps and medication libraries across all clinical areas, with specified concentrations and dosing safety limits.

    Verbatim wording from the response

    “The Trust is in the process of implementing infusion pumps with inbuilt dose error reduction software (DERS) throughout all clinical areas. Once the project has successfully been completed, clinical areas which use infusion pumps will utilise a medication library to infuse their drugs, if appropriate.”

    Source location

    2021-0399-Response-from-Oxford-University-Hospitals_Published
    Page 2 · response
    Published 29 November 2021

    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

    Educate staff to use medication libraries and not bypass safety limits except in exceptional circumstances.

    Verbatim wording from the response

    “Each medication library will contain a list of medications with specified concentrations and/or dosing safety limits to reduce the risk of infusion related incidents e.g., overdosing or underdosing. Resource will be allocated to ensure that medication entries on the libraries are accurate, relevant, and appropriate so that staff should not need to override safety limits if following usual practice; the software is designed not to be overridden if inappropriate dosing is entered outside of the safe limits put in place.”

    Source location

    2021-0399-Response-from-Oxford-University-Hospitals_Published
    Page 2 · response
    Published 29 November 2021

    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

    Investigate developing limits for entries in the Cerner infusion chart for selected narrow-dose-safety-profile drugs.

    Verbatim wording from the response

    “The issue raised refers to the current situation where a user can input a value for a drug infusion rate into the iView infusion section of the Cerner clinical system chart without any limits. This was identified as a contributing factor in the drug dosing error associated with Mr Hussain’s care.”

    Source location

    2021-0399-Response-from-Oxford-University-Hospitals_Published
    Page 2 · response
    Published 29 November 2021

    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

    Introduce new infusion pumps across all sites with bi-directional communication capability between pumps and the Cerner clinical system.

    Verbatim wording from the response

    “In addition, the Trust is in the process of introducing new infusion pumps across all sites. One of the requirements for the procurement of these pumps was that they should allow bi-directional communication between the pumps and the Cerner clinical system. This would allow auto-programming of the pump from the electronic prescription and would automatically update the hourly infusion rate recorded in the iView infusion section of the drug chart. If the bi-directional communication capability of these pumps were to be used, this would significantly reduce the volume of manually entered data and remove the risk of transcription errors by bedside nurses when programming pumps or recording infusion rates.”

    Source location

    2021-0399-Response-from-Oxford-University-Hospitals_Published
    Page 3 · response
    Published 29 November 2021

    Open published response

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