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.

10 Mar2014
Manchester North
Concerns raised2
1. Failure of care home management to identify carers’ non-compliance with drugs administration protocols
2. Failure of the drugs administration protocol to be fit for purpose and specific to the care home environment
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.

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

Derrick George RIVERS · 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

Derrick George Rivers, who had been admitted to full-time care after becoming frail and falling, was mistakenly given a 150mg dose of Clozapine intended for another resident. He was admitted to hospital with altered consciousness and confusion, initially improved, then deteriorated and died on 11 July 2013; the inquest found that he died from natural causes to which the Clozapine may have contributed. Concerns included inadequate medication policies and administration protocols, insufficient auditing and inspection, and incomplete implementation of recommendations intended to reduce the risk of medication errors.

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 care home management to identify carers’ non-compliance with drugs administration protocols
Wider context from the report
“3) That the care home owner and/or manager were purportedly unaware of the fact that carers were not following drugs administration protocols. ”
Source location
Derrick George RIVERS · 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 of the drugs administration protocol to be fit for purpose and specific to the care home environment
Wider context from the report
“5) That the care home’s drugs administration protocol was not fit for purpose and was tantamount to a ‘hybrid’ of other policies i.e. it was not specific to the care home environment. ”
Source location
Derrick George RIVERS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Mar2014
Manchester South
Concerns raised1
1. Failure to verify actual intravenous drug delivery when recording drug administration
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.

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

Afifa Qaisar · 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

Afifa Qaisar was admitted to Tameside General Hospital on 23 June 2013 with collapse and confusion, initially diagnosed as meningitis with sepsis, and died at 20.30 hours the same day. Concerns included uncertainty about whether drugs recorded as given had actually been administered, unavailability of required resuscitation equipment, failure to notify the RMO, delays in platelet and Hb support, an inappropriate response to an apparently non-running saline infusion, and failure to commence fluid balance monitoring or catheterisation.

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 actual intravenous drug delivery when recording drug administration
Wider context from the report
“1. During the course of the event it became apparent that the time of delivery/administration of various drugs was of the utmost importance. The nursing staff had completed the records to say that the drugs had been ‘given’. The Ward manager accepted that this simply meant that the drip had been ‘put up’ and did not confirm that the drug had actually been delivered into the vein of the patient. The husband of the patient contended that the ‘bag’ remained full and that he did not see any evidence that its contents were in fact administered to the patient. ”
Source location
Afifa Qaisar · Prevention of Future Deaths report
Page 1 · concerns
Open source report
28 Feb2014
County Durham and Darlington
Concerns raised3
1. Failure to provide the medication administration and holding policy in a protocol or policy statement to relevant staff
2. Failure to make the medication administration and holding policy known to prescribers
3. Unavailability of a protocol or policy statement on medication administration and holding
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Responsibility for safeguarding clients regarding prescribed medication lies with GPs, not the organisation.
  Stated by 700 ClubRedirects responsibility
AI-generated summary

Richard Philip WHITE · 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

Richard White was a resident at Hope House who took an overdose of cyclizine and zopiclone on 9 June 2013 and subsequently died from cyclizine toxicity. The concerns were that Hope House’s medication policy was not made known to the prescriber or others involved, was not set out in a protocol or policy statement, and that no such document was available.

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 provide the medication administration and holding policy in a protocol or policy statement to relevant staff
Wider context from the report
“1) That the policy of Hope House with regard to the administration and holding by staff of medication was not made known to ████████ when she wrote the prescriptions; 2) That the policy was not provided in a protocol, or policy statement, to ████████, or indeed, ████████ and ████████ 3) That no such protocol or policy statement was available. ”
Source location
Richard Philip WHITE · 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 make the medication administration and holding policy known to prescribers
Wider context from the report
“1) That the policy of Hope House with regard to the administration and holding by staff of medication was not made known to ████████ when she wrote the prescriptions; 2) That the policy was not provided in a protocol, or policy statement, to ████████, or indeed, ████████ and ████████ 3) That no such protocol or policy statement was available. ”
Source location
Richard Philip WHITE · 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
Unavailability of a protocol or policy statement on medication administration and holding
Wider context from the report
“1) That the policy of Hope House with regard to the administration and holding by staff of medication was not made known to ████████ when she wrote the prescriptions; 2) That the policy was not provided in a protocol, or policy statement, to ████████, or indeed, ████████ and ████████ 3) That no such protocol or policy statement was available. ”
Source location
Richard Philip WHITE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 safeguarding clients regarding prescribed medication lies with GPs, not the organisation.

Verbatim wording from the response
“I am writing to your practice on behalf of the 700 Club to remove any ambiguity relating to the storage or administration of medication by our organization. We do not, as a matter of policy, either store medication on behalf of our clients, nor do we administer medication to clients. Prescriptions issued to our clients by your practice should take the above information into account, particularly if that client is vulnerable and there is a concern that the client may use that medication inappropriately (self-harm, selling on). The responsibility for safeguarding clients in regard to prescribed medication lies with GP's.”

Source location
2014-0085-Response-by-700-Club2
Page 1 · response
Published 28 February 2014
Open published response
26 Feb2014
Black Country
Concerns raised1
1. Failure to withhold insulin when blood sugars are dangerously low
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

Bertram Theophilus HAMILTON · 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

Bertram Theophilus HAMILTON was a long-term care-home resident who died shortly after receiving insulin despite a recorded blood sugar level of 1.6. Concerns included the nurse appearing not to know that insulin should not be given when blood sugar was so low, and concerns about the nurse's account of events not being supported by contemporaneous documentation.

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 withhold insulin when blood sugars are dangerously low
Wider context from the report
“I am concerned that the nurse in question appeared not to know that insulin should not be given to a person whose blood sugars were so low. In addition, I was concerned that the nurse was not frank and open in giving evidence to me and claimed that she had given Mr. Hamilton a sugary solution, that she had re-checked his blood sugar and gave the insulin only after the blood sugar level was high. None of the contemporaneous documentation, including documentation completed by the nurse herself, supported such a contention. ”
Source location
Bertram Theophilus HAMILTON · Prevention of Future Deaths report
Page 1 · concerns
Open source report
19 Sep2013
Gloucestershire
Concerns raised1
1. Insufficient arrangements to support taking anti-convulsant medication
This report raised 2 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 8
1. Action
  Conduct internal medicines-management audits across all nine Trust communities to assess compliance with safety standards.
  Stated by The Camphill Village TrustStated completed
2. Action
  Implement a Trust-wide Medicines Policy governing the obtaining, recording, handling, storage, administration and disposal of medicines.
  Stated by The Camphill Village TrustStated completed
3. Action
  Carry out medicines-policy compliance checks at least every six months under the Operations Director’s direction.
  Stated by The Camphill Village TrustStated planned
1. Action
  Require documented medicine risk assessments, capacity assessments and support instructions, with six-monthly or trigger-based reviews.
  Stated by The Camphill Village TrustStated completed
2. Action
  Incorporate regular training on managing risks associated with medicines into the Trust staff training plan.
  Stated by The Camphill Village TrustStated completed
3. Action
  Audit risk-assessment, capacity-assessment and documented-medicine-support records at least every six months.
  Stated by The Camphill Village TrustStated planned
4. Action
  Share the Coroner’s concerns with operational managers to support open learning and required practice changes.
  Stated by The Camphill Village TrustStated planned
5. Action
  Implement common Trust-wide paperwork and work systems for identifying, assessing and managing medicine-related risks.
  Stated by The Camphill Village TrustStated planned
AI-generated summary

Daniel Onley · 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

Daniel Onley, a resident at Orchard House, was found face down in his bath on 22 June 2012 and was concluded to have died from sudden unexplained death in epilepsy. Concerns included insufficient support for taking anti-convulsant medication, inadequate management of medication-related risks, and insufficient evening supervision.

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
Insufficient arrangements to support taking anti-convulsant medication
Wider context from the report
“(1) That the arrangements in place to support Daniel to take his anti-convulsant medication were insufficient. ”
Source location
Daniel Onley · 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
Conduct internal medicines-management audits across all nine Trust communities to assess compliance with safety standards.

Verbatim wording from the response
“Audit of existing arrangements”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 1 · response
Published 19 September 2013
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
Implement a Trust-wide Medicines Policy governing the obtaining, recording, handling, storage, administration and disposal of medicines.

Verbatim wording from the response
“Policy revision”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 2 · response
Published 19 September 2013
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
Carry out medicines-policy compliance checks at least every six months under the Operations Director’s direction.

Verbatim wording from the response
“Future audit of arrangements”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 2 · response
Published 19 September 2013
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
Require documented medicine risk assessments, capacity assessments and support instructions, with six-monthly or trigger-based reviews.

Verbatim wording from the response
“Improvements to the management of risks associated with the administration of medicines in trust services”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 2 · response
Published 19 September 2013
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
Incorporate regular training on managing risks associated with medicines into the Trust staff training plan.

Verbatim wording from the response
“Regular training on the management of risks has been incorporated into the Trust’s staff training plan.”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 3 · response
Published 19 September 2013
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
Audit risk-assessment, capacity-assessment and documented-medicine-support records at least every six months.

Verbatim wording from the response
“Future audit of arrangements”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 3 · response
Published 19 September 2013
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
Share the Coroner’s concerns with operational managers to support open learning and required practice changes.

Verbatim wording from the response
“6 Organisational Learning”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 4 · response
Published 19 September 2013
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
Implement common Trust-wide paperwork and work systems for identifying, assessing and managing medicine-related risks.

Verbatim wording from the response
“The concerns expressed by the Coroner have been shared with operational managers in order to ensure lessons are learned openly and frankly and any required changes to practice are made. For example, as a result of organisational learning, common paperwork has been implemented across the Trust regarding the identification; assessment and management of risks related to handing medicines. The introduction of such a common paperwork and systems of work will greatly assist risk mitigation, improve consistency in operational practice and also provides an essential benchmark for quality auditing purposes.”

Source location
2013-0208-Response-by-The-Camphill-Village-Trust
Page 4 · response
Published 19 September 2013
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure of care home management to identify carers’ non-compliance with drugs administration protocols

Failure of the drugs administration protocol to be fit for purpose and specific to the care home environment

Concerns raised1

Failure to verify actual intravenous drug delivery when recording drug administration

Concerns raised3

Failure to provide the medication administration and holding policy in a protocol or policy statement to relevant staff

Failure to make the medication administration and holding policy known to prescribers

Unavailability of a protocol or policy statement on medication administration and holding

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 withhold insulin when blood sugars are dangerously low

Concerns raised1

Insufficient arrangements to support taking anti-convulsant medication

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.8

Respondent positions 1

Actions described in response 8