Recurring concern

Unsafe medication prescribing

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First reported 5 May 2013•Latest report 25 Jun 2026

Definition

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.

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
121

Distinct published reports

Individual concerns
151

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
246

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care20
NHS England16
Care Quality Commission7
NHS Greater Manchester Integrated Care Board7
General Medical Council6
National Institute for Health and Care Excellence4
Recipient name withheld4
Medicines and Healthcare products Regulatory Agency3
NHS Surrey and Sussex Integrated Care Board3
Royal College of General Practitioners3
Royal College of Physicians3
University Hospitals Birmingham NHS Foundation Trust3
Welsh Government3
BNF Publications2
Cwm Taf Morgannwg University Local Health Board2

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.

  1. South Wales Central

    AI-generated summary

    Mr. Donald Vernon Compton · 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

    Donald Vernon Compton, aged 87, was admitted to hospital after developing Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis and Covid-19, and died on 14 February 2021. The principal concerns were prescribing and dispensing errors involving Co-trimoxazole despite a known trimethoprim allergy, including failures by hospital staff and a GP to identify the risk. A separate medication error involving excessive amiodarone dosing was also identified.

    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 the electronic prescribing tool to require review of known allergies

    Wider context from the report

    “Prescribing and dispensing errors 1. At the time, the All Wales electronic prescribing tool (eDAL) permitted prescribers to avoid reading the section concerning known allergies; 2. The commonly prescribed antibiotic Co-trimoxazole comprises two constituent drugs trimethoprim and sulfamethoxazole. Allergies were not noted as Co-trimoxazole but to the constituent drug, trimethoprim. 3. Prescribing hospital doctors; overseeing pharmacist; and ward nurses all failed to pick up on this discharge prescribing and dispensing error suggesting drug safety on discharge is an area for scrutiny and input to ensure a similar error is avoided a patient safety is maximised. 4. That the Torbay GP also made an error in prescribing Co-trimoxazole to Mr. Compton in the knowledge he was allergic to trimethoprim indicates the lack of specific knowledge about this antibiotic and its constituent elements. It may also reflect a more general lack of knowledge about constituent components of commonly prescribed drugs. 5. A different prescribing error was made in respect of this same patient whilst under the care of RGH. The down titration of Amiodarone was overlooked resulting in too high a dose being administered over several days. ”

    Source location

    Mr. Donald Vernon Compton · 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 knowledge about constituent components of commonly prescribed drugs

    Wider context from the report

    “Prescribing and dispensing errors 1. At the time, the All Wales electronic prescribing tool (eDAL) permitted prescribers to avoid reading the section concerning known allergies; 2. The commonly prescribed antibiotic Co-trimoxazole comprises two constituent drugs trimethoprim and sulfamethoxazole. Allergies were not noted as Co-trimoxazole but to the constituent drug, trimethoprim. 3. Prescribing hospital doctors; overseeing pharmacist; and ward nurses all failed to pick up on this discharge prescribing and dispensing error suggesting drug safety on discharge is an area for scrutiny and input to ensure a similar error is avoided a patient safety is maximised. 4. That the Torbay GP also made an error in prescribing Co-trimoxazole to Mr. Compton in the knowledge he was allergic to trimethoprim indicates the lack of specific knowledge about this antibiotic and its constituent elements. It may also reflect a more general lack of knowledge about constituent components of commonly prescribed drugs. 5. A different prescribing error was made in respect of this same patient whilst under the care of RGH. The down titration of Amiodarone was overlooked resulting in too high a dose being administered over several days. ”

    Source location

    Mr. Donald Vernon Compton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. Sunderland

    AI-generated summary

    Mr Alan Hodgson · 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 Alan Hodgson died at Sunderland Royal Hospital on 14 January 2021. The report describes failures to recognise the severity of his condition, delays in acting on and reporting imaging, failures to follow the vascular pathway, inadequate communication and continuity of care, and an insufficient review of the circumstances leading 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

    Failure to ascertain the indication and appropriateness of opiate analgesia

    Wider context from the report

    “(1) Signing and administration of opiate analgesia to a patient without any evidence of ascertaining why such analgesia was required, and if it was appropriate; ”

    Source location

    Mr Alan Hodgson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. West Yorkshire (Western)

    AI-generated summary

    Sharon Anne ROBINSON · 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

    Sharon Robinson died at Airedale Hospital on 7 February 2019 after an antibiotic administered on 27 January induced an anaphylactic reaction. The principal concern was that a possible patient sensitivity to an antibiotic might be disregarded and the antibiotic given despite that 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

    Failure to act on patients' antibiotic sensitivity

    Wider context from the report

    “There is a concern that when a patient may have a sensitive to anti-biotic despite the low risk, this will be ignored and anti-biotic be given in any event. ”

    Source location

    Sharon Anne ROBINSON · 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

    Discussed the case with senior clinical leaders across the Trust and wider regional healthcare organisations to promote consistent allergy-risk decision-making.

    Verbatim wording from the response

    “• Case discussed at the Senior Medical Leadership Group meeting. This includes all Clinical Directors and Divisional Medical Directors within Airedale NHS Foundation Trust.”

    Source location

    2021-0385-Response-from-Airedale-General-Hospital_Published
    Page 2 · response
    Published 19 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Discussed the case through the Yorkshire and Humber Antimicrobial Pharmacists Network to disseminate learning on safe prescribing with recorded allergies.

    Verbatim wording from the response

    “• The Trust Antimicrobial Pharmacist has discussed this case at the Yorkshire and Humber Antimicrobial Pharmacists Network.”

    Source location

    2021-0385-Response-from-Airedale-General-Hospital_Published
    Page 2 · response
    Published 19 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Align the antimicrobial approach across Bradford Teaching Hospitals and Airedale Hospitals, including revising the Antimicrobial Policy using evidence-based practice.

    Verbatim wording from the response

    “• Chief Pharmacist and Executive Medical Director are working to align the approach for Bradford Teaching Hospitals and Airedale Hospitals, which will be overseen by the Drug and Therapeutics Committee. This includes revision of the Antimicrobial Policy – to build in best evidence-based practice with experts to implement safe patient care.”

    Source location

    2021-0385-Response-from-Airedale-General-Hospital_Published
    Page 2 · response
    Published 19 November 2021

    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

    A documented antibiotic allergy is not necessarily ignored when clinicians investigate its history and make an evidence-based, clinically considered prescribing decision.

    Verbatim wording from the response

    “I would then like to address the suggestion that a patient’s sensitivity to an antibiotic would be ‘ignored’ and an antibiotic given in any event. In the case of Mrs Robinson, the Trust’s evidence given at inquest was that Mrs Robinson’s recorded allergy to Penicillin was not ‘ignored’. It was carefully considered when the treating clinician exercised their clinical decision making around whether or not it would be appropriate and safe to administer Amoxicillin (Penicillin-based antibiotic) for a Lower Respiratory Tract Infection (‘LRTI’) in January 2019. The Trust’s evidence was that, before deciding to prescribe Amoxicillin, the patient had reported to clinical staff that, notwithstanding the ‘allergy alert’ on her file, she”

    Source location

    2021-0385-Response-from-Airedale-General-Hospital_Published
    Page 1 · response
    Published 19 November 2021

    Open published response
  4. Birmingham and Solihull

    AI-generated summary

    Christopher COLLINSON · 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

    Christopher Collinson was admitted to Birmingham Heartlands Hospital with suspected deep vein thrombosis and pulmonary embolism, but was not seen by a doctor for several hours. He was prescribed a prophylactic rather than therapeutic dose of Enoxaparin, later suffered a cardiac arrest, and died on 15 June 2021. Concerns related to the patient-allocation system not making it clear when an allocated patient had not been seen, and the electronic prescribing system not requiring a secondary medication check.

    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 the electronic prescribing system to require a secondary medication-selection check

    Wider context from the report

    “2. The current electronic prescribing system does not require a Doctor to perform a secondary check that they have selected the correct medication. I am concerned that it is all too easy to select the wrong medication, particularly when the department is busy and Doctors are under pressure. This could lead to fatal outcomes for patients if given incorrect medication. ”

    Source location

    Christopher COLLINSON · 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

    Additional prescribing double-checks are unlikely to improve safety and may increase risk through alert fatigue.

    Verbatim wording from the response

    “There is however little evidence to suggest that introducing an additional double-check into the individual prescriber’s workflow improves patient safety. On the other hand, there is evidence of risks associated with introducing many more alerts. This is a consequence of alert fatigue discussed in more detail below.”

    Source location

    2021-0361-Response-from-Queen-Elizabeth-Hospital_Published
    Page 3 · response
    Published 2 November 2021

    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

    Existing EPMA systems and processes sufficiently minimise medication risk, so no additional prescribing double-check is introduced.

    Verbatim wording from the response

    “Based on the review of our systems and relevant literature, we are confident that the systems and processes that we have in place are sufficient to minimise risk to our patients. We are satisfied that our decision not to introduce an additional double-check step has been carefully considered and is consistent with the collective approach of those responsible for introducing and maintaining EPMA systems.”

    Source location

    2021-0361-Response-from-Queen-Elizabeth-Hospital_Published
    Page 4 · response
    Published 2 November 2021

    Open published response
  5. Leicester City and South Leicestershire

    AI-generated summary

    Jamie Francis O'Connor · 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

    Jamie O’Connor was found deceased in the garden of his home in Leicester on 14 October 2018 after his mother became concerned that he was not responding to phone calls. The report identified concerns about online prescribing, including the lack of central tracking, limited information sharing with GPs, no required face-to-face consultation, limited questionnaires, patients requesting specific drugs, and limited regulation; the inquest concluded that this was a drug-related death and recorded the cause as ████████ toxicity.

    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 flag refusal to share prescribing information for further enquiry

    Wider context from the report

    “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. ”

    Source location

    Jamie Francis O'Connor · 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 prevent drug selection before prescriber contact

    Wider context from the report

    “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. ”

    Source location

    Jamie Francis O'Connor · 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

    Inspect online providers’ management of medicines, prescriptions, consent, identity checks, information sharing, governance and staff safety training.

    Verbatim wording from the response

    “For those providers who fall within the CQC’s scope of regulation we inspect against the regulations using an inspection framework. All providers must comply with the regulations as set out in The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (RAR 2014). The regulations that would be most relevant to any reviews around online providers, would include, but not be limited to, the following:”

    Source location

    2021-0363-Response-from-CQC_Published
    Page 2 · response
    Published 4 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Publish guidance requiring providers to inform patients’ GPs about prescribed medications and assess safety when patients decline information sharing.

    Verbatim wording from the response

    “CQC has published guidance for providers¹. The guidance describes the expectations of providers to ensure a patient’s GP is informed of prescribed medications from their service. We also expect that should the patient decline to consent for the sharing”

    Source location

    2021-0363-Response-from-CQC_Published
    Page 2 · response
    Published 4 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Publish updated prescribing guidance covering remote consultation suitability, information sharing, patient dialogue, and safeguards for controlled or potentially addictive medicines.

    Verbatim wording from the response

    “Following this exercise, we published updated guidance for doctors on prescribing in February 2021. This now places a greater emphasis on following the principles of good practice regardless of the medium through which a consultation is taking place, face to face or online.”

    Source location

    2021-0363-Response-from-GMC_Published
    Page 1 · response
    Published 4 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish high-level principles for safe remote consultations and online prescribing with healthcare organisations.

    Verbatim wording from the response

    “We have also worked with other healthcare organisations including regulators, royal colleges and faculties and have jointly-agreed High level principles for good practice in remote consultations and prescribing that set out the good practice of healthcare professionals when prescribing medication online. The ten principles, underpinned by existing expected standards and guidance, include that healthcare professionals are expected to:”

    Source location

    2021-0363-Response-from-GPC_Published
    Page 3 · response
    Published 4 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Launch a call for evidence on remote consultations and prescribing to assess whether existing guidance remained appropriate for changing practice and technology.

    Verbatim wording from the response

    “I appreciate that the events giving rise to this inquest date from several years ago. In late 2019 we launched a call for evidence in relation to remote consultations and prescribing. This explored whether our existing guidance, which was last updated in 2013 and which applied at the time of Mr O’Connor’s death, had kept pace with changes in practice and the use of technology.”

    Source location

    2021-0363-Response-from-GMC_Published
    Page 1 · response
    Published 4 November 2021

    Open published response
  6. Manchester South

    AI-generated summary

    Elaine Michelle Inns · 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

    Elaine Michelle Inns was found dead at her home on 18 January 2021. The inquest heard that she continued to be prescribed powerful painkillers despite significant alcohol use and use of liquid morphine without clearly following dosage instructions; the medical cause of death involved the combined toxic effects of ethanol and prescribed medicines.

    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 significant alcohol use when prescribing powerful painkillers

    Wider context from the report

    “The inquest heard that Elaine Inns continued to be prescribed a combination of medication including a number of powerful painkillers although it was well understood that she was also using alcohol in significant quantities whilst taking her prescribed medication. The evidence before the court also indicated that she would use the prescribed liquid morphine without clearly following the recommended dosage instructions. She continued to be prescribed it. ”

    Source location

    Elaine Michelle Inns · 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

    Share up-to-date opiate prescribing guidance across Stockport practices.

    Verbatim wording from the response

    “Having reviewed this overall investigation and the circumstances which led to the issue of your Regulation 28 report, I reach the conclusion that the key issue is the prescribing of opiates and I am satisfied that appropriate steps have been taken to ensure the safe prescribing of opiate medication at the individual practice and across the wider Stockport GP community. I will ensure that the most up to date opiate prescribing guidance is shared across our practices and work with colleagues across our system to ensure adherence to best practice guidance.”

    Source location

    2021-0285-Response-from-Stockport-CCG_Published.pdf
    Page 4 · response
    Published 2 September 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Work with system colleagues to ensure adherence to best-practice opiate prescribing guidance.

    Verbatim wording from the response

    “Having reviewed this overall investigation and the circumstances which led to the issue of your Regulation 28 report, I reach the conclusion that the key issue is the prescribing of opiates and I am satisfied that appropriate steps have been taken to ensure the safe prescribing of opiate medication at the individual practice and across the wider Stockport GP community. I will ensure that the most up to date opiate prescribing guidance is shared across our practices and work with colleagues across our system to ensure adherence to best practice guidance.”

    Source location

    2021-0285-Response-from-Stockport-CCG_Published.pdf
    Page 4 · response
    Published 2 September 2021

    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

    Existing prescribing safeguards are considered sufficient to ensure safe opiate prescribing across the individual practice and wider Stockport GP community.

    Verbatim wording from the response

    “Having reviewed this overall investigation and the circumstances which led to the issue of your Regulation 28 report, I reach the conclusion that the key issue is the prescribing of opiates and I am satisfied that appropriate steps have been taken to ensure the safe prescribing of opiate medication at the individual practice and across the wider Stockport GP community. I will ensure that the most up to date opiate prescribing guidance is shared across our practices and work with colleagues across our system to ensure adherence to best practice guidance.”

    Source location

    2021-0285-Response-from-Stockport-CCG_Published.pdf
    Page 4 · response
    Published 2 September 2021

    Open published response
  7. East London

    AI-generated summary

    Anita Mandalia · 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

    Anita Mandalia took an overdose of prescribed medications at home on 7 February 2021 and died in hospital on 11 February 2021 from complications of the overdose. Concerns included prescribing beyond recommended guidance, failure to re-refer her to mental health services when concerns arose, and prescribing pain medication that gave her access to an excess of medication despite overdose-risk mitigation measures.

    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 limit prescribing of the medication to the recommended duration

    Wider context from the report

    “1. Mrs Mandalia had been prescribed ████████ NICE guidance and BNF guidance stipulated that this medication ought not to be prescribed for longer than ████████ Mrs Mandalia had received that prescription far longer than the recommended period. The GP surgery had not checked the appropriateness of that prescription. ”

    Source location

    Anita Mandalia · 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 check the appropriateness of medication prescriptions

    Wider context from the report

    “1. Mrs Mandalia had been prescribed ████████ NICE guidance and BNF guidance stipulated that this medication ought not to be prescribed for longer than ████████ Mrs Mandalia had received that prescription far longer than the recommended period. The GP surgery had not checked the appropriateness of that prescription. ”

    Source location

    Anita Mandalia · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. East London

    AI-generated summary

    Samantha Singh · 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

    Samantha Singh developed a suspected nut allergy, was assessed as having a mixed nut allergy, and was prescribed an EpiPen. On 25 July 2020, she became unwell at home and suffered a cardiac arrest attributable to anaphylactic shock; she could not be resuscitated. The concerns included the miscategorisation of her test results, prescription of only one EpiPen, and lack of referral to an allergy clinic or follow-up appointment.

    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 at least two EpiPens

    Wider context from the report

    “(2) At a GP appointment on 27 November 2019, Miss Singh was prescribed a single EpiPen. NICE guidance at the time indicated that no fewer than two epi-pens should be prescribed to a patient. ”

    Source location

    Samantha Singh · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  9. Essex

    AI-generated summary

    Fiona May Humberstone · 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

    Fiona May Humberstone, who had longstanding mental health conditions, alcohol misuse and chronic pain, died at home from an inadvertent overdose of prescribed Oromorph taken with other medication. The concerns included mental health clinicians relying solely on patients’ accounts of their medication and inadequate access to accurate, up-to-date prescribing information between primary and secondary care.

    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

    Reliance on patients’ accounts of current medication without routine verification

    Wider context from the report

    “(1) In her statement provided for the purposes of the inquest, FH’s consultant psychiatrist listed the medications prescribed to FH at the time of her death but made no reference to the Oromorph. During the course of her oral evidence she confirmed that, at the time of her last review of FH in April 2020, she was entirely unaware that she had been prescribed this powerful morphine-based pain killer for a number of months. She also confirmed that had she known of the prescription for that medication it would have affected her risk assessment, given LH’s continuing misuse of alcohol. She told the court that it was (and remains) her usual practice to rely entirely on the information regarding medication (including dosage and frequency) provided by the patient, even in telephone only consultations. She stated that she would only rarely (and certainly not routinely) check the accuracy of the account provided by obtaining a list of medication from the GP or other clinical records. Although not causative in respect of FH’s death, I am concerned that the practice of relying entirely on a patient’s account of current medication, in circumstances where significant mental health issues are often involved (including where there is chronic substance and/or alcohol misuse) gives rise to a serious risk of future deaths. As was accepted by the witness, any risk assessments, care plan reviews or further prescribing of (or alteration to) a medication regimen may in such circumstances be predicated upon incomplete, inaccurate and potentially dangerously misleading information. In my view the risk of future deaths is clear. ”

    Source location

    Fiona May Humberstone · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Manchester South

    AI-generated summary

    Steven Terence Allen · 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

    Steven Terence Allen was found unresponsive at home on 25 October 2020, and toxicology found a fatal level of prescribed medication; the medical cause of death was recorded as combined drug toxicity. Concerns included prescribing oxycodone and other medications despite a history of addiction, self-harm and poor use of substances, with telephone consultations during Covid-19 and additional replacement prescriptions sometimes issued with little challenge.

    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 addiction, self-harm and poor substance use when prescribing medication

    Wider context from the report

    “The inquest heard that he had a chaotic lifestyle and a history of drug addiction. He was in significant pain and was prescribed medication to manage his pain including oxycodone. He was prescribed this and additional medications although there was a history of addiction, self-harm and poor use of prescribed and illicit substances. Prescribing of these medications was done through telephone consultations due to Covid 19 and on occasion additional replacement prescriptions were given with little challenge. ”

    Source location

    Steven Terence Allen · 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

    Continue discussions with Primary Care Network leads to explore Stockport Integrated Pharmacy Service support for optimising medication reviews.

    Verbatim wording from the response

    “• The Medicines Management Team is currently in discussion with the Primary Care Network (PCN) Leads to explore how the Stockport Integrated Pharmacy Service (SIPS) can support GP Practices in optimising medication reviews for this patient cohort.”

    Source location

    2021-0190-Response-from-Stockport-Clinical-Commissioning-Group-Redacted
    Page 2 · response
    Published 4 June 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Remind Stockport GPs about available opioid-prescribing resources and how to seek support through the next pharmacy newsletter.

    Verbatim wording from the response

    “Greater Manchester Medicines Management Group (GMMMG) Opioid Prescribing for Chronic Pain: Resource Pack”

    Source location

    2021-0190-Response-from-Stockport-Clinical-Commissioning-Group-Redacted
    Page 2 · response
    Published 4 June 2021

    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

    Existing prescribing guidance and clinician adherence are considered sufficient because the incident is regarded as isolated.

    Verbatim wording from the response

    “The Practice take on board the comments included within the Regulation 28 Report and have undertaken a review of this case and looked at their processes for the management of prescribing for patients in this vulnerable cohort. The practice are satisfied that this was an isolated case and that all clinicians do adhere to guidance in relation to informed prescribing and support of this patient group.”

    Source location

    2021-0190-Response-from-Stockport-Clinical-Commissioning-Group-Redacted
    Page 1 · response
    Published 4 June 2021

    Open published response
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Data last updated 7 September 2026