Recurring concern

Inadequate communication of opioid toxicity risks

First to latest report 28 Aug 2019 — 31 Mar 2025

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
2

What this concern includes

Includes failures of controls specifically intended to communicate, explain or reinforce opioid-toxicity risks to patients, carers or relevant clinicians, including risks from lost tolerance after abstinence, renal accumulation, combined opioid use and related overdose or respiratory-depression hazards.

What is not included
  • Excludes general medication counselling or patient-information deficiencies where opioid toxicity is not the material safety concern.
  • Excludes opioid prescribing, dosage, quantity, administration or monitoring failures where communication of opioid-toxicity risks is not the deficient control.
  • Excludes treatment failures after opioid toxicity or overdose has occurred unless the assertion also identifies inadequate opioid-risk communication.
  • Excludes warnings about non-opioid medicines or unrelated medication hazards.

Reports and published responses 4 reports

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

  1. Inner North London

    AI-generated summary

    Abu RAHMAN · 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

    Abu Rahman, aged 88, suffered a traumatic fall causing a fractured hip and underwent hemi-arthroplasty before deteriorating with pneumonia on a background of end stage renal failure. Concerns included delays in obtaining Naloxone when supplies ran out and limited awareness of opioid toxicity or accumulation in patients with kidney impairment or failure.

    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 awareness of opioid toxicity and accumulation risks in patients with kidney impairment or failure

    Wider context from the report

    “Firstly, I heard evidence from the family that nursing staff were frequently unable to administer Naloxone as it had run out. They had to obtain more Naloxone from the pharmacy, which led to delays for “hours and hours” on multiple occasions. Secondly, I heard evidence concerning a lack of awareness or appreciation concerning the risk of opioid toxicity / accumulation in patients with kidney impairment/failure, even where the “correct” dose may have been given. I am concerned that if there is no proper or properly implemented system for obtaining medication in a timely manner, and limited awareness of the matters canvassed above, then this gives rise to a risk of future deaths. ”

    Source location

    Abu RAHMAN · 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 and distribute local adult opioid-toxicity management guidelines, including interim advice based on national best-practice guidance.

    Verbatim wording from the response

    “It is recognised that the process of initiating Naloxone in Dr Rahman’s case was not in line with available best practice guidance. Bolus injections of Naloxone are recommended, to assess the response from the patient and an infusion is commenced thereafter with the dose titrated according to the amount required to achieve an initial response. It is acknowledged that awareness of this process should be shared amongst the medical team in the Acute”

    Source location

    Response from Royal Free Hospital
    Page 1 · response
    Published 1 April 2025

    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

    Expert review concluded that the patient was unlikely to have experienced opioid toxicity, contrary to the concern raised.

    Verbatim wording from the response

    “Considering Dr Rahman’s diagnosis of end stage renal failure the half-life (the time it takes for the amount of a drug’s active substance in your body to reduce by half) of oxycodone in patients increases by up to 1.7 times compared to patients with normal renal function. A review by a Consultant Nephrologist and Lead Renal Pharmacist confirmed that the final dose of Oxycodone administered at 10:04 on 11 November 2024 would have been expected to have been metabolised that afternoon. From the information gathered, following a review of the patient’s medical records with input from an expert panel, it was concluded that the patient in this case was unlikely to have opioid toxicity.”

    Source location

    Response from Royal Free Hospital
    Page 3 · response
    Published 1 April 2025

    Open published response

  2. County Durham and Darlington

    AI-generated summary

    Andrew James Naylor · 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

    Andrew James Naylor was found deceased on 11 October 2022 in Durham City, the day after discharge from hospital following treatment for a drug overdose and alcohol withdrawal. The report identified concerns about inadequate warnings of the risks associated with combining the administered drug with alcohol or drugs, poor communication between services, and insufficient consideration of his homelessness, discharge safety, and available support. The inquest concluded that he died from the combined central nervous system depressant actions of alcohol and two drugs, with cumulative failures contributing more than minimally to his 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

    Lack of a protocol or policy for warning patients about acute respiratory depression and death risks from alcohol or drug misuse after administration of the drug

    Wider context from the report

    “(1) There is no specific protocol or policy in place to ensure that patients are warned of the acute risk of respiratory depression and death following administration of the drug ████████ should they drink alcohol or misuse drugs. ”

    Source location

    Andrew James Naylor · 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

    Review and update the acute alcohol withdrawal policy to include patient advice, using stakeholder input, and obtain approval by September 2024.

    Verbatim wording from the response

    “The Trust has a Management of Acute Alcohol Withdrawal Policy which has been extended until September 2024 to enable the Organisation to explore the most appropriate, and safest, way to include the suggestion raised by yourself. This will require careful stakeholder”

    Source location

    Response from CDDFT
    Page 1 · response
    Published 30 July 2024

    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

    The chlordiazepoxide concern is for CDDFT to address, and CDDFT has reportedly responded.

    Verbatim wording from the response

    “I am writing to you in response to the Prevention of Future Death (PFD) Report issued to Tees, Esk and Wear Valleys NHS Foundation Trust ("TEWV", or "the Trust") on 04.06.2024 following the inquest touching the death of Andrew Naylor. I note that the PFD Report issued has been directed to both TEWV and County Durham and Darlington NHS Foundation Trust (CDDFT), on the basis you have concerns in respect of both organisations. I have not responded to point 5(1) as this issue relating to Chlordiazepoxide, appears to be for CDDFT to respond to and I am assured that they have responded.”

    Source location

    Response from Tees, Esk and Wear Valleys NHS Foundation Trust
    Page 1 · response
    Published 30 July 2024

    Open published response

  3. Inner North London

    AI-generated summary

    Kenneth John Daly · Prevention of Future Deaths report

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

    Report summary

    Kenneth John Daly, who had chronic pain and anxiety and was prescribed multiple medications, was found dead at home on 4 December 2018. The inquest concluded that his death was drug related, involving multi-drug toxicity, after he overdosed on Morphine, Dihydrocodeine and Codeine alongside Pregabalin and benzodiazepine medication. Concerns included unclear guidance about using multiple opioid medications together and the absence of tailored written advice for Mr Daly.

    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 written advice on the risks of combining multiple opioids

    Wider context from the report

    “1) In oral evidence, the Consultant stated that no other opioids were to be taken once Morphine Sulphate and Co-Codamol had been prescribed but that prescribing of Pregabalin could continue. She set out her advice in a letter to Mr Daly’s GP dated 11 July 2018. The letter clearly stated that Fentanyl and Tapentadol should be stopped and Morphine sulphate (MST) 60mg started. The advice regarding the prescribing of pain relieving medications other than Fentanyl and Tapentadol is less clear. In relation to Dihydrocodeine and Tramadol it is stated that “He can continue using the Dihydrocodeine and very rarely Tramadol until he sees you for his next prescription. Together with the MST, I would recommend to allow him Co-Codamol 30/500mg 2 tablets up to four times a day...”. Following receipt of the letter, Tramadol and Dihydrocodeine continued to be issued by the GP practice albeit at lower quantities than previously prescribed. The GP did not seek any further guidance regarding the advice given in the letter of 11 July 2018 from the Consultant. 2) Mr Daly was a patient that was known to adjust his pain medication without seeking guidance from his GP. Whilst Mr Daly was copied in to the letter sent to his GP on 11 July 2018, he was not given any written guidance regarding his pain relief and the use of other medications (such as benzodiazepines) that was tailored to his needs as a patient. Specifically, he was not given any written advice regarding the risks of using multiple opioid medications in combination. ”

    Source location

    Kenneth John Daly · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  4. London (West)

    AI-generated summary

    Amir Siman-Tov · 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

    Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.

    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 apply renal impairment information in codeine overdose assessment

    Wider context from the report

    “6. Mr Siman-Tov was taken to the Hillingdon Hospital in the late morning following his overdose on the 16ᵗʰ February 2016. At the Hillingdon Hospital an assessment, examination and blood tests were taken. The blood tests indicated renal impairment. An information system TOXBASE is used in emergency departments to provide assistance to clinicians. Toxbase indicates that in renal impairment greater care must be taken in cases of codeine overdose. This was missed. ”

    Source location

    Amir Siman-Tov · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

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

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Data last updated 7 September 2026