Recurring concern

Unsafe medication prescribing

First to latest report 5 May 2013 — 25 Jun 2026

Reports that mention this concern
121
Times this concern has been raised
151
Stated actions linked to this concern
246

What this concern includes

Includes failures involving the clinical appropriateness of prescribing or medication selection, including inadequate assessment of indication, patient circumstances, relevant information, alternatives or dose.

What is not included
  • Excludes failures limited to medication administration after an otherwise appropriate prescription.
  • Excludes generic documentation, training or communication deficiencies unless they directly result in or are explicitly tied to an unsafe prescribing decision.
  • Excludes dispensing, supply or monitoring failures that do not concern whether the medication prescription itself was clinically appropriate.

Reports and published responses 121 reports

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

  1. Manchester South

    AI-generated summary

    Peter Arthur Rowe · 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 Arthur Rowe was administered the penicillin-based antibiotic co-amoxiclav despite a GP referral letter recording a penicillin allergy. He developed a worsening rash, was admitted to hospital with toxic epidermal necrolysis, and died on 8 February 2016 following deterioration. Concerns included the deletion of recorded allergy information and reliance on allergy answers despite Mr Rowe’s poor memory and his wife’s lack of knowledge of his allergy.

    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 prevent prescribing and administration of penicillin-based antibiotics despite a recorded penicillin allergy

    Wider context from the report

    “1. That despite the GPs referral letter stating an allergy to penicillin, a penicillin based prophylactic antibiotic was prescribed and administered. ”

    Source location

    Peter Arthur Rowe · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Blackburn, Hyndburn and Ribble Valley

    AI-generated summary

    Karen Ravenscroft · 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

    Karen Ravenscroft fell at home on 11 March 2016 and fractured her left arm and leg. She was assessed as being at high risk of venous thromboembolism but was not prescribed appropriate prophylaxis, subsequently developed a deep vein thrombosis, and died from a fatal pulmonary embolus. Concerns included the absence of thromboprophylaxis, failure to reassess VTE risk or provide mechanical prophylaxis, and limitations in electronically prescribing drugs from the Accident & Emergency Department.

    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 prescribe pharmacological thromboprophylaxis for patients at high risk of venous thromboembolism without contraindications

    Wider context from the report

    “1. The initial venous thromboembolism risk assessment done during the admission as per the Trust’s VTE Guidelines stated that Mrs Ravenscroft was at high risk for VTE with no bleeding risk and no contra-indication for pharmacological thromboprophylaxis. Despite that no thromboprophylaxis was prescribed. ”

    Source location

    Karen Ravenscroft · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. East London

    AI-generated summary

    EMMA LOUISE BRAY · 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

    Emma Louise Bray had a history of problems with mood and was assessed by mental health services in January 2015 after her mood deteriorated. Her family reported worsening symptoms, hopelessness, suicidal research and concerns about her medication, but several planned referrals, follow-up actions and communication of information did not occur. She hanged herself on 25 February 2015. Concerns included incomplete medication and treatment histories, failures in follow-up and referral, inadequate response to family information, failures to record emails, unclear medication-risk communication, and wider deficiencies in service guidance and monitoring.

    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 guidance on medication recommendations without a full medical history

    Wider context from the report

    “During the evidence I was told that a number of things had not happened that ought to have done: (a) A proper medication history was not taken on assessment (b) EB’s treatment and medication history were not obtained from either public or private sector providers. (c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days. (d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition. (e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team. (f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring. (g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment. (h) There should have been regular contact with EB thereafter, initiated by IT. (i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care. (j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment. (k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns. (l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay. On a systemic level, the following issues are of concern: (a) Absence of guidelines about what information must be obtained on assessment, including the medication history. (b) Absence of guidance about where that information should be obtained from: the patient / primary sources. (c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services. (d) Lack of clarity about who should be the person between patients and the IT. (e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them. (f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be. (g) An absence of guidelines giving staff timescales within which referrals should take place. (h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place. (i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history. (j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person. (k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of. (l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes. (m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff. ”

    Source location

    EMMA LOUISE BRAY · 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

    Lack of guidance on medication recommendations without seeing the patient in person

    Wider context from the report

    “During the evidence I was told that a number of things had not happened that ought to have done: (a) A proper medication history was not taken on assessment (b) EB’s treatment and medication history were not obtained from either public or private sector providers. (c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days. (d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition. (e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team. (f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring. (g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment. (h) There should have been regular contact with EB thereafter, initiated by IT. (i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care. (j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment. (k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns. (l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay. On a systemic level, the following issues are of concern: (a) Absence of guidelines about what information must be obtained on assessment, including the medication history. (b) Absence of guidance about where that information should be obtained from: the patient / primary sources. (c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services. (d) Lack of clarity about who should be the person between patients and the IT. (e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them. (f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be. (g) An absence of guidelines giving staff timescales within which referrals should take place. (h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place. (i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history. (j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person. (k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of. (l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes. (m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff. ”

    Source location

    EMMA LOUISE BRAY · 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 implement AABIT standard operating procedures.

    Verbatim wording from the response

    “The plan has five broad objectives within which your specific concerns have been addressed. These are:”

    Source location

    2015-0438-Response-by-NELFT-NHS-Trust
    Page 1 · response
    Published 16 November 2015

    Open published response

  4. Worcestershire

    AI-generated summary

    Wayne Patrick O'NEILL · 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

    Wayne Patrick O'NEILL was a serving prisoner at HMP Long Lartin who collapsed in his cell and died on 2 January 2013. The inquest recorded respiratory failure, bronchospasm following ingestion of propranolol, and asthma as the medical cause of death. Concerns included the prescribing of propranolol despite asthma, the combination of psychotropic medicines with potential cardiac effects, and the failure to undertake an ECG before 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

    Failure to account for asthma contraindications when prescribing propranolol

    Wider context from the report

    “(1) the evidence revealed that Mr O'Neill had died from one of two causes; either, as the jury found, he had taken propranolol illicitly which induced the broncho spasm that caused his respiratory failure. It is worth noting that Mr O'Neill had previously been prescribed propranolol and evidence was given at the inquest by a forensic psychiatrist that the fact it was contra indicated (given Mr O'Neill's asthma) appeared "to have been lost" to the prescribing clinicians at the time. The alternative cause of death was that Mr O'Neill died from acute cardiac failure induced by the combination of psychotropic medication prescribed to him including citalopram, Olanzapine and amitriptyline. An alert had previously been raised by the Medicines Healthcare Regulatory Authority warning against the prescribing of these drugs in combination. An attempt had been made to take Mr O'Neill off these drugs but subsequent clinician had re-introduced them. It was not clear from the evidence that when Mr O'Neill was screened in reception following his transfer from HMP Birmingham to HMP Long Lartin the significance of these combinations of medication was recognised. Expert evidence was heard during the cause of the inquest notably from ████████ a Cardiologist. He said there was a strong case for ECG traces to be performed on all prisoners in receipt of this medication. This would reveal whether there was any prolongation of the QT interval. The evidence revealed that an ECG trace had not been undertaken during the years that Mr O'Neill was an inmate at HMP Birmingham. A trace was arranged at HMP Long Lartin but had not taken place by the time of Mr O'Neill's death having only been requested as a matter of routine. The evidence suggested that the reason why the ECG was requested was due to an elevated pulse rate detected at the reception screen rather than recognition of the potentially toxic effects of the prescribed medication. Evidence was given that obtaining an ECG trace is a simply, cheap and straight forward matter. It would seem sensible, accordingly for all the prisoners in receipt of this combination of medication to undergo ECG traces as part of the reception screening process. ”

    Source location

    Wayne Patrick O'NEILL · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Birmingham and Solihull

    AI-generated summary

    Hireiti Kufletsion · 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

    Hireiti Kufletsion died at Queen Elizabeth Hospital Birmingham on 20 November 2014 from thrombosis of a mechanical mitral valve during the first trimester of pregnancy. The report identified failures to adequately investigate the valve, seek specialist cardiology advice and prescribe adequate doses of clexane, with concerns that pregnant women with mechanical heart valves may be at risk from insufficient anticoagulation and inadequate clinical understanding of the associated thrombosis risk.

    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 clexane dosing for pregnant women with mechanical valves

    Wider context from the report

    “(1) In giving evidence ████████ stated that from time to time she does see at her Obstetric/Cardiac clinic pregnant patients with mechanical valves who have had their warfarin changed to clexane at other hospitals in the region on too low a dose of clexane (i.e. not a twice daily 60mg/kg dose). Likewise she is aware that review of anti-factor Xa may not be arranged to occur with adequate frequency (once a week). Therefore pregnant women with mechanical valves may be at risk from being prescribed insufficient doses of clexane with insufficient review of their anti-factor Xa. ”

    Source location

    Hireiti Kufletsion · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester West

    AI-generated summary

    Dorothy Delaney · 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

    Dorothy Delaney was found collapsed at her care home on 11 June 2015 after being prescribed Rivaroxaban for atrial fibrillation and Clopidogrel for previous transient ischaemic attacks. She was diagnosed with a large intracerebral haemorrhage and died later that day. The principal concern was that both anticoagulant and antiplatelet medications were prescribed without individual specialist advice, increasing the risk of haemorrhage.

    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 obtain individualized specialist advice for patients prescribed anticoagulation and antiplatelet medication together

    Wider context from the report

    “vi. Following Mrs Delaney’s diagnosis of atrial fibrillation and the subsequent prescription of Rivaroxaban, no specialist advice was sought regarding the appropriateness of continuing to prescribe both Clopidogrel and Rivaroxaban together. Evidence was given at the inquest that advice is not sought on an individual basis for patients at Alexander House Health Centre who are prescribed both Clopidogrel and Rivaroxaban as they rely on advice previously sought in respect of other patients in similar circumstances. 2. I therefore have concerns that there are patients under the care of Alexander House Health Centre who are being prescribed both anticoagulation therapy and antiplatelet medication at the same time, which increases the risk of a haemorrhage occurring, in circumstances where specialist advice has not been sought, taking into account the individual patient’s previous medical history and circumstances. ”

    Source location

    Dorothy Delaney · 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

    Produce a practice protocol for prescribing anticoagulant and antiplatelet medicines together.

    Verbatim wording from the response

    “Although I was not able to find any protocol or guidance on this issue, as I have feedback from our local Haematology Department, I decided to produce a protocol for our practice for future prescribing of anticoagulant with antiplatelet agents. Furthermore I have reviewed all the patients who are on combined treatment. I have looked at their medical records and checked the suitability of the patient to be on both groups of medication. In any patient, if I was not sure, I have liaised with secondary care to clarify the matter.”

    Source location

    2015-0402-Alexander-House-Health-Centre
    Page 2 · response
    Published 23 September 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

    Review all patients receiving combined anticoagulant and antiplatelet treatment, checking documented suitability and consulting secondary care when uncertain.

    Verbatim wording from the response

    “Although I was not able to find any protocol or guidance on this issue, as I have feedback from our local Haematology Department, I decided to produce a protocol for our practice for future prescribing of anticoagulant with antiplatelet agents. Furthermore I have reviewed all the patients who are on combined treatment. I have looked at their medical records and checked the suitability of the patient to be on both groups of medication. In any patient, if I was not sure, I have liaised with secondary care to clarify the matter.”

    Source location

    2015-0402-Alexander-House-Health-Centre
    Page 2 · response
    Published 23 September 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

    Change prescriptions to single anticoagulant treatment where appropriate after discussing the decision with each patient.

    Verbatim wording from the response

    “I felt on reviewing their records, most of the patients could be managed by a singly anticoagulant agent instead of combined treatment, as per our local Haematology guidance. Accordingly I made the”

    Source location

    2015-0402-Alexander-House-Health-Centre
    Page 2 · response
    Published 23 September 2015

    Open published response

  7. Brighton and Hove

    AI-generated summary

    Mr. Isaac BAHAR · 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. Isaac Bahar was admitted to hospital after a fall caused fractured ribs and a traumatic pneumothorax. Despite known stage four chronic kidney disease, he was prescribed and given codeine in contravention of national and local guidance, and later developed opioid toxicity and died. The inquest found the prescribing error was one of the causes of his death; chronic obstructive pulmonary disease was also deemed a contributory factor.

    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 prescribe analgesia in accordance with guidance for patients with Stage 4 Chronic Kidney Disease

    Wider context from the report

    “Mr. Bahar was admitted to the Royal Sussex County Hospital on 10th November 2014 with pneumothorax due to fractured ribs. He was treated urgently and appropriately until his analgesia. He was a man with known Stage 4 Chronic Kidney Disease, yet in breach of the hospital’s own policy and in breach of national guidance he was prescribed and given four doses of Codeine over 18 hours. Although this was stopped by the ward Pharmacist as soon as she was able to review his drug chart, Mr. Bahar collapsed with severe opiate/opioid toxicity 30 hours later and died just under three hours after the collapse. The Jury at his Inquest found this error to be one of the causes of his death The Codeine was directed by a locum surgical consultant and the fatal error was compounded when a locum junior doctor wrote up the Codeine in Mr. Bahar’s drug chart. Their locum status must be relevant and if the Trust employs locum staff they must satisfy themselves that those staff are aware of such guidance particularly in such a common scenario (elderly patient with Chronic Kidney Disease needing analgesia). The Trust is responsible for ensuring their patients are in safe hands. Senior nurses should also be aware of such common pitfalls. They would then be in a position when caring for their patients to pick up anomalies. This is a serious failing and must be urgently addressed. ”

    Source location

    Mr. Isaac BAHAR · 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

    Stop making codeine routinely available for prescription by general surgeons.

    Verbatim wording from the response

    “This incident, and the sad death of Mr Bahar, has been discussed in detail with both the general surgeons and the nursing team on Level 9a, as well as with the pharmacy team. As a direct result, the general surgeons decided that codeine should no longer be routinely available for them to prescribe. Discussions are continuing to seek a consensus as to whether the benefits of withdrawing codeine altogether from use within the Trust by other specialists would outweigh the associated disadvantages of such a step.”

    Source location

    2015-0229-Response-by-Brighton-and-Sussex-University-Hospitals-Trust
    Page 2 · response
    Published 15 June 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

    Continue discussions to determine whether withdrawing codeine from Trust-wide use by other specialists would outweigh the disadvantages.

    Verbatim wording from the response

    “This incident, and the sad death of Mr Bahar, has been discussed in detail with both the general surgeons and the nursing team on Level 9a, as well as with the pharmacy team. As a direct result, the general surgeons decided that codeine should no longer be routinely available for them to prescribe. Discussions are continuing to seek a consensus as to whether the benefits of withdrawing codeine altogether from use within the Trust by other specialists would outweigh the associated disadvantages of such a step.”

    Source location

    2015-0229-Response-by-Brighton-and-Sussex-University-Hospitals-Trust
    Page 2 · response
    Published 15 June 2015

    Open published response

  8. Manchester South

    AI-generated summary

    David Glyn Price · 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

    David Glyn Price suffered a heart attack in early June 2011 and underwent surgery at Wythenshawe Hospital, during which a swab was inadvertently left inside his body attached to his heart; this gradually formed an abscess. Concerns included continued warfarin prescribing despite missed anticoagulation appointments, poor handwritten clinical records, failure to act on imaging showing a foreign body, and inadequate swab-count 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 to review or discontinue repeat prescriptions when medicines are no longer needed or when required monitoring is missed

    Wider context from the report

    “1.Before he was admitted to hospital his G.P. was prescribing warfarin and this continued over many months despite the fact that he failed on three occasions to attend the anti- coagulation clinic. There is apparently no system to prevent this happening. I have noted in many inquests that people who have “repeat prescriptions” continue to get all the drugs prescribed even if they are no longer needed or wanted, thus potentially placing the patient at considerable health risk but also costing the NHS a vast amount of money for unwanted and unused drugs.(For the Secretary of State) ”

    Source location

    David Glyn Price · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Inner South London

    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

    Prescribing multiple medicines without a sufficiently complete clinical assessment and medication history

    Wider context from the report

    “4. ████████ ████████ was represented at the inquest and the following evidence gave rise to concerns: • He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison. • When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam. • He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing. • He said that he did not know whether he should stop Methadone if the BP was low. • Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy. • At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered. • At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered. • He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives. ”

    Source location

    Laurence Boyens · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Leicester City and South Leicestershire

    AI-generated summary

    Rafal Delezuch · 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

    Rafal Delezuch was seen behaving bizarrely and showing paranoia in Leicester before being restrained by police under section 136 of the Mental Health Act and taken to hospital. The inquest concluded that he died from amphetamine-induced delirium in association with prolonged struggle. Concerns included staff awareness and training on restraint, lack of familiarity with the dangers of prolonged prone restraint, difficulties obtaining and selecting medication for rapid tranquillisation, and an overlooked warning about diazepam in NICE guidance.

    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 pursue appropriate quick-acting medication alternatives for rapid tranquilisation

    Wider context from the report

    “(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy. (2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position (3) When it was decided that the patient was in need of rapid tranquilisation then: a) A supply of Lorazepam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazepam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated. (4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked. ”

    Source location

    Rafal Delezuch · 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

    Develop a shared rapid tranquillisation guideline with the Leicestershire Partnership Trust, including appropriate consideration of relevant NICE guidance.

    Verbatim wording from the response

    “In addition, our Chief Pharmacist has met with the Leicestershire Partnership Trust to develop a shared rapid tranquillisation guideline; our Clinical Director will ensure that this guideline is in place by the end of May 2015. This Guideline will also deal with appropriate consideration of the relevant NICE Guidelines.”

    Source location

    2015-0024-Response-by-University-Hospitals-of-Leicester
    Page 2 · response
    Published 27 January 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

    Put the shared rapid tranquillisation guideline in place in the Emergency Department.

    Verbatim wording from the response

    “In addition, our Chief Pharmacist has met with the Leicestershire Partnership Trust to develop a shared rapid tranquillisation guideline; our Clinical Director will ensure that this guideline is in place by the end of May 2015. This Guideline will also deal with appropriate consideration of the relevant NICE Guidelines.”

    Source location

    2015-0024-Response-by-University-Hospitals-of-Leicester
    Page 2 · response
    Published 27 January 2015

    Open published response

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

Back to top

Data last updated 7 September 2026