Recurring concern

Unsafe medication administration

Get email alerts

Request correction

First reported 19 Sep 2013•Latest report 19 Mar 2026

Definition

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.

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: 115
Individual concerns: 147
Date range: 2013–2026
Stated actions: 192

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission7

Stockport NHS Foundation Trust7

Department of Health and Social Care6

Ministry of Justice4

NHS England4

Tameside and Glossop Integrated Care NHS Foundation Trust4

HM Prison and Probation Service3

Nursing and Midwifery Council3

University Hospitals Sussex NHS Foundation Trust3

Barking, Havering and Redbridge University Hospitals NHS Trust2

Care UK2

Hc-One Limited2

Leeds Prison2

Leeds Teaching Hospitals NHS Trust2

Manchester University NHS Foundation Trust2

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.

27 Aug2015
Manchester South
Concerns raised1
1. Lack of staff training in prescribed-drug administration
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Frederick Sutton · 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

Frederick Sutton fell and broke his hip at home on 3 February 2015, may have suffered a myocardial infarction, and died approximately 12 hours after admission to hospital. The concerns included hospital staffing levels, escalation procedures, failures to read nursing notes, incompatible computerised record systems, inadequate staff training, response to cardiac arrest, medication administration, and inaccurate next-of-kin information.

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 staff training in prescribed-drug administration
Wider context from the report
“(5) The patient required the administration of cyclizane and there was an obvious problem with the (lack of) training of the staff in this regard. (6) The patient suffered a cardiac arrest and there was a lack of understanding amongst nursing and medical staff as to how this ought to have been responded to. (7) There seemed to be a lack of training amongst the staff as to the administration of certain prescribed drugs, both as to the appropriate amount thereof and the method of delivery. ”
Source location
Frederick Sutton · Prevention of Future Deaths report
Page 1 · concerns
Open source report
14 Jul2015
Nottinghamshire
Concerns raised1
1. Failure to administer indicated prescription drugs
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Thomas Farrell · 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

Thomas Farrell died after becoming unwell with a chest infection while resident at Springfield Care Home and being admitted to hospital, where he died on 16 July 2014. The principal concern was that the care home had not obtained a full medication record from his GP, resulting in several prescribed medicines not being administered; the report stated this omission did not cause or contribute to his death but posed a clear risk in other circumstances.

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 administer indicated prescription drugs
Wider context from the report
“1. That the Home did not know the true extent of the prescription drugs which were indicated for Mr Farrell while he was a resident, having not approached Mr Farrell’s GP for a full record. The result of this was that the prescription drugs aspirin, senna, doxalil and omeprazole were not given. Whilst in the event this did not cause or contribute to his death on 16th July 2014, the risk of such an omission causing death in other circumstances is clear. ”
Source location
Thomas Farrell · Prevention of Future Deaths report
Page 1 · concerns
Open source report
22 Apr2015
Inner South London
Concerns raised3
1. Failure to identify and act on drowsiness before controlled-drug administration
2. Failure to review blood-pressure trends before controlled-drug administration
3. Failure to suspend controlled drugs and escalate low blood pressure
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Laurence Boyens · 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

Laurence Boyens died in prison on 15 November 2012 from Methadone, Tramadol and Diazepam intoxication. The jury identified concerns about the combination and interaction of prescribed drugs, failures to monitor intoxication symptoms and blood pressure, and failures to suspend or withhold Methadone and Tramadol when signs of toxicity were present.

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 identify and act on drowsiness before controlled-drug administration
Wider context from the report
“1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug. • Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading • The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP • The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all • A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th. • One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP. • One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor. • The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur. • The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays. • In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies. • No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”. • At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol. • On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review. ”
Source location
Laurence Boyens · 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
Failure to review blood-pressure trends before controlled-drug administration
Wider context from the report
“1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug. • Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading • The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP • The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all • A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th. • One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP. • One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor. • The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur. • The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays. • In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies. • No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”. • At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol. • On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review. ”
Source location
Laurence Boyens · 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
Failure to suspend controlled drugs and escalate low blood pressure
Wider context from the report
“1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug. • Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading • The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP • The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all • A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th. • One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP. • One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor. • The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur. • The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays. • In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies. • No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”. • At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol. • On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review. ”
Source location
Laurence Boyens · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 Mar2015
Manchester South
Concerns raised1
1. Failure of doctors in training to administer every dose of long-acting insulin
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Commission and complete a diabetes-care Task and Finish Group review, producing an approved action plan.
  Stated by Stockport NHS Foundation TrustStated completed
2. Action
  Amend the Trust Training Needs Analysis to require diabetes training for nurses and doctors.
  Stated by Stockport NHS Foundation TrustStated completed
3. Action
  Purchase and incorporate an NHS England-recommended diabetes e-learning module into the Training Needs Analysis.
  Stated by Stockport NHS Foundation TrustStated completed
1. Action
  Add diabetes and insulin management to mandatory three-yearly Essentials training for all staff.
  Stated by Stockport NHS Foundation TrustStated completed
2. Action
  Provide specialist insulin-prescribing and diabetes-management training to medical staff when they commence.
  Stated by Stockport NHS Foundation TrustStated completed
AI-generated summary

Pamela Pattison · 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

Pamela Pattison was admitted to hospital after falling at home and fracturing her hip. Her insulin was intentionally omitted following a mistaken assessment, and concerns were raised about sub-optimal diabetic care, inadequate staff training and escalation, insufficient specialist diabetes support, equipment and resourcing problems, and delay in transferring her to an appropriate ward. The medical cause of death was recorded as aspiration pneumonia following nausea and vomiting consequent upon unstable diabetic control, with brittle diabetes and a fractured neck of femur also recorded.

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 doctors in training to administer every dose of long-acting insulin
Wider context from the report
“2. ALL the doctors in training need to be aware that they should not omit any dose of 'long-acting insulin'. The consultant expressed the 'hope' that they would know this, but the evidence suggested the contrary. ”
Source location
Pamela Pattison · 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
Commission and complete a diabetes-care Task and Finish Group review, producing an approved action plan.

Verbatim wording from the response
“One of our most important actions was the internal commissioning of a “Task and Finish Group” whose remit was “to review the current situation regarding diabetes care to ensure safe and ████████ for all patients with diabetes in hospital”. This was chaired by ████████ Head of Risk and Customer Services, and included senior medical staff, experienced diabetes specialists (both nursing and medical) and senior nurses from across the Trust. I understand the action plan from this group was also shared with you during the inquest.”

Source location
2015-0108-Stockport-NHS-Trust
Page 1 · response
Published 23 March 2015
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
Amend the Trust Training Needs Analysis to require diabetes training for nurses and doctors.

Verbatim wording from the response
“a. The Trust Training Needs Analysis (TNA) has been amended to include diabetes training as an essential requirement for all nurses and doctors (see below).”

Source location
2015-0108-Stockport-NHS-Trust
Page 1 · response
Published 23 March 2015
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
Purchase and incorporate an NHS England-recommended diabetes e-learning module into the Training Needs Analysis.

Verbatim wording from the response
“b. An E-Learning module has been purchased by the Trust (one recommended by NHS England) completion of which is included in the TNA.”

Source location
2015-0108-Stockport-NHS-Trust
Page 2 · response
Published 23 March 2015
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
Add diabetes and insulin management to mandatory three-yearly Essentials training for all staff.

Verbatim wording from the response
“d. ‘Essentials’ training (that which is mandatory for all staff every three years) now includes a session on diabetes and insulin management.”

Source location
2015-0108-Stockport-NHS-Trust
Page 2 · response
Published 23 March 2015
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
Provide specialist insulin-prescribing and diabetes-management training to medical staff when they commence.

Verbatim wording from the response
“Medical staff in training: On bespoke induction and complete eLearning module for ‘Safe use of insulin’ every three years”

Source location
2015-0108-Stockport-NHS-Trust
Page 2 · response
Published 23 March 2015
Open published response
2 Mar2015
Staffordshire South
Concerns raised1
1. Failure to conduct drugs rounds in accordance with the requirement for more than one staff member
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Peter Jonathan Wright · 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 Jonathan Wright, a voluntary patient at St George’s Hospital, died after deliberately cutting an artery in his neck with a broken metal fork. The concerns included understaffing, failure to record necessary observations, a nurse undertaking a drugs round alone contrary to policy, and the lack of an on-site doctor and out-of-hours medical cover.

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 conduct drugs rounds in accordance with the requirement for more than one staff member
Wider context from the report
“(1) At the time of the death the ward was understaffed. Of the quota staff of three, one care assistant had been called to assist in another ward (and had in fact just returned) and one care assistant was with another patient who required continuous observation. This left just the qualified nurse to deal with 16 patients. She did not record all necessary observations and was doing a drugs round by herself (contrary to policy). This was recognised in the SIR carried out by ████████ but no recommendation was made about it on the basis that the Trust was undergoing a major staffing review in any event. It may therefore be that the situation has already been addressed but this was not clear to me at the Inquest and the impression I received from the nurse was that there is now some extra support at times but it is still not satisfactory. ”
Source location
Peter Jonathan Wright · Prevention of Future Deaths report
Page 1 · concerns
Open source report
17 Feb2015
Mid Kent and Medway
Concerns raised1
1. Failure of agency staff to understand medication administration and medication refusal policies and procedures
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Send monthly SMS reminders to all staff about documentation, escalation, medication administration and compassion.
  Stated by Mayday Healthcare plcStated completed
2. Action
  Send quarterly formal letters to staff reinforcing documentation, escalation, medication administration and compassion.
  Stated by Mayday Healthcare plcStated completed
3. Action
  Update the yearly training programme on documentation, escalation, medication administration and compassion beyond mandatory training requirements.
  Stated by Mayday Healthcare plcStated completed
AI-generated summary

George Marks · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

George Marks was admitted with confusion, immobility and a chest infection, and was later diagnosed with a deep vein thrombosis and a thrombus in the pulmonary artery. After his anticoagulant medication was changed to Rivaroxaban, he was not given it from the evening of 28 February until 4 March, and he died on 6 March 2014. The principal concerns were agency staff’s failures in medication administration, record-keeping and handover procedures.

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 agency staff to understand medication administration and medication refusal policies and procedures
Wider context from the report
“1) Agency staff failed to have an understanding of the basic policies and procedures in place when administering medication and / or where a patient refused to take such medication. ”
Source location
George Marks · 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
Send monthly SMS reminders to all staff about documentation, escalation, medication administration and compassion.

Verbatim wording from the response
“• A generic SMS has been sent to all staff detailing the importance of documentation, escalation, administration of medication and compassion. This is done once a month to remind all staff of their basic duties.”

Source location
2015-0057-Response-by-Mayday-Healthcare
Page 1 · response
Published 17 February 2015
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
Send quarterly formal letters to staff reinforcing documentation, escalation, medication administration and compassion.

Verbatim wording from the response
“• Formal letters sent to all staff, detailing the importance of documentation, escalation, administration of medication and compassion. This is currently being done every quarter.”

Source location
2015-0057-Response-by-Mayday-Healthcare
Page 1 · response
Published 17 February 2015
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
Update the yearly training programme on documentation, escalation, medication administration and compassion beyond mandatory training requirements.

Verbatim wording from the response
“• Updated our yearly training program in regards to documentation, escalation, administration of medication and compassion, which is outside of the framework requirements for the Mandatory Training subjects”

Source location
2015-0057-Response-by-Mayday-Healthcare
Page 2 · response
Published 17 February 2015
Open published response
28 Dec2014
Mid Kent and Medway
Concerns raised1
1. Failure to verify medication ingestion before recording administration
This report raised 27 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Dispense most medication under supervision, use liquid medication where risk assessment indicates, and verify ingestion before recording administration.
  Stated by Oxleas NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Responsibility for administering prescribed medication rests with Oxleas NHS Foundation Trust, while CNWL provides urgent review when non-compliance is reported.
  Stated by Central and North West London NHS Foundation TrustRedirects responsibility
AI-generated summary

Alex Kelly · 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

Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to verify medication ingestion before recording administration
Wider context from the report
“Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
Source location
Alex Kelly · Prevention of Future Deaths report
Page 3 · 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
Dispense most medication under supervision, use liquid medication where risk assessment indicates, and verify ingestion before recording administration.

Verbatim wording from the response
“The majority of medications are now dispensed under supervised conditions and, where risk assessment deems it appropriate, in liquid form. Young people are asked to demonstrate the medication has been taken by opening their mouths. Staff will only then record that the medication has been administered using the electronic clinical record (SystmOne). If there are concerns about the possible diversion or failure to ingest medication, this is recorded and the relevant persons notified. This includes completing a security report and informing wing staff and other clinicians, such as CAMHS.”

Source location
2014-0555-Response-by-Oxleas-NHS-Trust
Page 2 · response
Published 28 December 2014
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Responsibility for administering prescribed medication rests with Oxleas NHS Foundation Trust, while CNWL provides urgent review when non-compliance is reported.

Verbatim wording from the response
“Oxleas NHS Foundation Trust have responded in detail on this point, as it is their staff who administered prescribed medications in HMYOI Cookham Wood. However, it is our responsibility to provide urgent medical and psychological review of young people who we are informed are non-compliant with prescribed medication, as they could be; a) ‘stockpiling’ medication with which to overdose, b) ‘trading’ it as an abusable commodity, c) they may feel that the medication is simply not helping them.”

Source location
2014-0555-Response-by-Central-North-West-London-NHS-Trust
Page 3 · response
Published 28 December 2014
Open published response
26 Nov2014
Surrey
Concerns raised1
1. Failure to seek appropriate senior medical advice before administering medication to a patient with a known allergy
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Require registrar-or-above authorisation and documentation before administering medication known to cause a patient’s allergy.
  Stated by Frimley Health NHS Foundation TrustStated completed
2. Action
  Develop and ratify a dedicated Management of Allergies policy incorporating the changed allergy-management requirements.
  Stated by Frimley Health NHS Foundation TrustStated in progress
3. Action
  Communicate the changed allergy-management practice to medical teams through Trust forums and committees.
  Stated by Frimley Health NHS Foundation TrustStated completed
1. Action
  Review nursing staff drug-assessment competency requirements to incorporate the changed allergy-management practice into theory and practical testing.
  Stated by Frimley Health NHS Foundation TrustStated in progress
AI-generated summary

Marjory Rosina ELLERY · 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

Marjory Rosina Ellery was taken to Frimley Park Hospital with chest pains and was administered medication to which she was known to be allergic. She developed anaphylactic shock and died on 16 January 2014; concerns related to administering medication despite a known allergy and obtaining informed consent in those circumstances.

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 seek appropriate senior medical advice before administering medication to a patient with a known allergy
Wider context from the report
“1. Action is required to ensure that medication is not administered to a patient to which they are known to have an allergy without advice being sought from a doctor of appropriate designated seniority or experience. ”
Source location
Marjory Rosina ELLERY · 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
Require registrar-or-above authorisation and documentation before administering medication known to cause a patient’s allergy.

Verbatim wording from the response
“The Trust has made the decision that any patient who requires a medication that they are known to have an allergy to, the decision to give this medication must be authorised by a registrar or above and documented in the notes.”

Source location
2014-0519-Response-by-Frimley-Health-NHS-Trust
Page 1 · response
Published 26 November 2014
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
Develop and ratify a dedicated Management of Allergies policy incorporating the changed allergy-management requirements.

Verbatim wording from the response
“These significant changes in practice have been presented to, and agreed at, both the Trust Quality & Safety Committee and Medication Safety Committee. The guidance on allergies was included in the Trust’s Record Keeping Guideline but as a result of these changes in practice a new policy has been developed on”

Source location
2014-0519-Response-by-Frimley-Health-NHS-Trust
Page 1 · response
Published 26 November 2014
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
Communicate the changed allergy-management practice to medical teams through Trust forums and committees.

Verbatim wording from the response
“These changes in practice have already been communicated to the medical teams by the Medical Director and the Lead nurses at a variety of Trust Forums and committees. The monthly Patient Safety Training for all nursing staff has been reviewed and amended to include training on the management of allergies. In addition, the Trust is in the process of reviewing its current drug assessment competency for nursing staff to include the changes in practice as part of the theory and practical test.”

Source location
2014-0519-Response-by-Frimley-Health-NHS-Trust
Page 2 · response
Published 26 November 2014
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
Review nursing staff drug-assessment competency requirements to incorporate the changed allergy-management practice into theory and practical testing.

Verbatim wording from the response
“These changes in practice have already been communicated to the medical teams by the Medical Director and the Lead nurses at a variety of Trust Forums and committees. The monthly Patient Safety Training for all nursing staff has been reviewed and amended to include training on the management of allergies. In addition, the Trust is in the process of reviewing its current drug assessment competency for nursing staff to include the changes in practice as part of the theory and practical test.”

Source location
2014-0519-Response-by-Frimley-Health-NHS-Trust
Page 2 · response
Published 26 November 2014
Open published response
17 Nov2014
Manchester South
Concerns raised1
1. Failure to activate intravenous antibiotic infusions
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Elsie Mallalie u · 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

Mrs Elsie Mallaliu fell at home on 12 August 2013, broke her hip, was admitted to hospital, and died four days later. The report raised concerns that she was moved to an inappropriate ward, where staff were not trained to use her high-flow oxygen, records and observations were inadequate, staffing pressures affected care, and antibiotics were not administered because the drip was not turned on. It also stated that she was considered “written off”, that a DNAR should not have been placed, and that escalation to ITU/HDU might have allowed treatment of the infection that led to her death.

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 activate intravenous antibiotic infusions
Wider context from the report
“5. A Consultant agreed with my conclusion that this patient was “written off” and that a DNAR should not have been placed and that she could have been escalated to ITU/HDU where the infection which in fact led to her death, might have been treatable. Whilst on ward 41 she was administered antibiotics for this condition but the nursing staff had failed to “turn on “the drip delivering the drug. ”
Source location
Elsie Mallalie u · Prevention of Future Deaths report
Page 1 · concerns
Open source report
14 Oct2014
Manchester South
Concerns raised1
1. Failure to connect syringe drivers for delivery of prescribed medication
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Alan Charles Peck · 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

Alan Charles Peck had been an inpatient at Tameside Hospital for approximately six weeks, underwent a hemi-colectomy, and was then discharged to Willow Wood Hospice. Concerns were raised that his syringe driver was not connected while he was on the surgical ward and that he was deprived of medication during transfer to the hospice.

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 connect syringe drivers for delivery of prescribed medication
Wider context from the report
“1. Whilst a patient on the surgical ward at Tameside Hospital, it was noted by his family that although he was prescribed medication to be delivered by syringe driver, the said driver was unconnected under the patient’s bed thus meaning that the essential drugs and analgesia were not being delivered to him. ”
Source location
Alan Charles Peck · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of staff training in prescribed-drug administration

Concerns raised1

Failure to administer indicated prescription drugs

Concerns raised3

Failure to identify and act on drowsiness before controlled-drug administration

Failure to review blood-pressure trends before controlled-drug administration

Failure to suspend controlled drugs and escalate low blood pressure

Concerns raised1

Failure of doctors in training to administer every dose of long-acting insulin

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Failure to conduct drugs rounds in accordance with the requirement for more than one staff member

Concerns raised1

Failure of agency staff to understand medication administration and medication refusal policies and procedures

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to verify medication ingestion before recording administration

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to seek appropriate senior medical advice before administering medication to a patient with a known allergy

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Actions described in response 5

Actions described in response 3

Actions described in response 1

Respondent positions 1

Actions described in response 4