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. East Riding and Kingston Upon Hull

    AI-generated summary

    Stuart Andrew WALLS · 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

    Stuart Andrew WALLS was found dead in his room on 12 March 2017 after being last seen alive the previous morning. The inquest concluded that he died from drug poisoning caused by the combined effects of prescribed medication, with concern that multiple central-nervous-system medicines could have a synergistic effect on respiration even when taken at prescribed doses.

    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 the totality and synergistic effects of prescribed central nervous system and respiratory-depressant medication

    Wider context from the report

    “Stuart died as a result of drug poisoning. However, there was no evidence of illicit drug use (other than cannabis which the Consultant Histopathologist confirmed had not played a part in the death). All prescribed drugs in his blood were within the therapeutic range. The Consultant Histopathologist explained that the prescribed drugs had combined in a synergistic effect, acting together to poison Stuart. My concern is that in the prescription of medication, particularly those that act on the central nervous system and affect respiration control, full account should be taken of the totality of drugs prescribed and their potential synergistic effect. The reasons for my concern are: Four prescription drugs namely Diazepam, Pregabalin, Amitriptyline and Promethazine were all found at a level consistent with therapeutic use. Each of these alone was at a level not expected to kill however each can exacerbate the effect of the other. I understood from the evidence that each of the drugs have a direct effect on the central nervous system. In particular a depressive effect on respiration. The Consultant Histopathologist confirmed this to be the case. In addition to those prescribed drugs, methadone was also prescribed at 60 mg daily. That is well within normal prescription range. It was found at a level of 507ng/mL in blood. Methadone also has an effect on the central nervous system and is another respiratory depressor. The toxicology report said: “...the deceased was prescribed 60mg of methadone daily. It has been reported that in 20 long-term opiate addicts who were administered a mean oral dose of 60mg methadone (range 10-225mg), the peak blood methadone concentrations ranged between 124-1255 ng/mL. It has been reported that in a study of 18 patients maintained on methadone 7.5 to 130 mg daily for at least 2 months, peak plasma concentrations of 69-698 ng/mL (pre-dose concentrations: 44-614 ng/mL) were achieved in 3 hours. The blood methadone level in the deceased was 507 ng/mL which may, therefore, reflect therapeutic use”. It is of course, not known how much methadone Stuart had taken or when. However, properly taking the prescribed dose could still achieve the recorded level. To put the amount of methadone into context, the toxicology evidence indicated a therapeutic range of 75 – 1100 ng/ml in blood; a toxic range of 200 – 2000 ng/ml and a fatal range of 400 – 2000 ng/mL. A level of tolerance builds with regular use. Methadone is a potent opioid narcotic analgesic and would also have a synergistic effect together with the other four drugs mentioned above. Therefore, even taking the properly prescribed medication as prescribed could have led to the situation that resulted in the death of Stuart WALLS. That is, drugs properly prescribed and properly taken could achieve a level, acting synergistically, that caused drug toxicity sufficient to cause death. ”

    Source location

    Stuart Andrew WALLS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. South Wales Central

    AI-generated summary

    Deidre Harvey · 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

    Deidre Harvey died on 19 April 2017 after attaching a dressing gown cord to her neck in a mental health unit bathroom; the cause of death was recorded as hanging. The report raised concerns about coordination between mental-health and outside consultants, management of ligature risks and dangerous items, risk-assessment communication, and the potential toxicity and monitoring of hydroxychloroquine.

    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 Hydroxychloroquine toxic accumulation at recommended doses

    Wider context from the report

    “Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”

    Source location

    Deidre Harvey · 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

    Seek expert pharmacovigilance advice on available evidence concerning hydroxychloroquine toxicity and the reported death.

    Verbatim wording from the response

    “On 21st November 2018, we sought the advice of the Commission on Human Medicines’ Pharmacovigilance Expert Advisory Group (PEAG) on the available data including the information outlined in the report of Mrs Harvey’s death. The PEAG advised that in order to ensure that any actions are evidence based, further details on the report would be helpful.”

    Source location

    2018-0266-Response-by-MHRA
    Page 1 · response
    Published 20 July 2017

    Open published response

  3. Exeter and Greater Devon

    AI-generated summary

    Carly Marie GORDON · 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

    Carly Marie GORDON was admitted to hospital after a failed attempt on her own life and was later found hanging at home on 27 May 2016 after being discharged to her mother's care. The inquest concluded that she took her own life while suffering from depressive disorder and benzodiazepine withdrawal; concerns related to the long-term prescribing and review of benzodiazepines.

    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 longer-acting rather than shorter-acting benzodiazepines for long-term use

    Wider context from the report

    “(1) The long term use of shorter acting Benzodiazepine instead of longer acting Benzodiazepine in accordance with the British Association of Psychopharmacology Guidelines should be followed when patients are prescribed this drug to avoid dependence. ”

    Source location

    Carly Marie GORDON · 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

    Request national mental health leads to write to all mental health trust medical directors and chief pharmacists, raising benzodiazepine prescribing and withdrawal risks and disseminating relevant guidance.

    Verbatim wording from the response

    “It is important that prescribers and pharmacists are aware of the risks associated with the use of benzodiazepines when prescribing or dispensing these medicines. In response to the specific concerns raised in your letter, I will ask ████████ ████████ our National Clinical Director for mental health, and ████████ our Head of Mental Health and LD Medicines Strategy to write to all medical directors and chief pharmacists in mental health trusts in England to:”

    Source location

    2017-0320-Response-by-NHS-England
    Page 2 · response
    Published 3 December 2017

    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 future prescribing practice regarding switching short-acting benzodiazepines to longer-acting alternatives.

    Verbatim wording from the response

    “• “Switching from a short half-life Benzodiazepine to a long half-life Benzodiazepine before gradual taper should be reserved for patients having problematic withdrawal symptoms”.”

    Source location

    2017-0320-Response-by-Fremington-Medical-Centre
    Page 2 · response
    Published 3 December 2017

    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

    BAP guidance does not require universal substitution of shorter-acting benzodiazepines; prescribing choice and duration depend on individual clinical judgment.

    Verbatim wording from the response

    “1) The long term use of shorter acting benzodiazepine instead of longer acting benzodiazepine in accordance with the British Association of Psychopharmacology guidelines should be followed when patients are prescribed this drug to avoid dependence; and”

    Source location

    2017-0320-Response-by-NHS-England
    Page 1 · response
    Published 3 December 2017

    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

    Switching to a long-acting benzodiazepine was not considered warranted in this case because clinical indications outweighed the risks.

    Verbatim wording from the response

    “• “Switching from a short half-life Benzodiazepine to a long half-life Benzodiazepine before gradual taper should be reserved for patients having problematic withdrawal symptoms”.”

    Source location

    2017-0320-Response-by-Fremington-Medical-Centre
    Page 2 · response
    Published 3 December 2017

    Open published response

  4. South Wales Central

    AI-generated summary

    Percy Jacks · 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

    Percy Jacks died from a pulmonary embolus after being found unresponsive the morning following treatment for chest pain. The report identified failings in the management of his anticoagulation medication, including poor communication between the hospital, GP surgery and care home, and inadequate systems for ensuring the medication continued for the intended period.

    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 of GP prescribing on receipt of hospital scan-result notification

    Wider context from the report

    “(2) The system within the GP surgery for prescribing Rivaroxaban was poor and relied solely on receiving the notification of the results of the scan from the hospital. There was no facility to review the medication to ensure that the correct dosage for the correct period of time continued to be prescribed. ”

    Source location

    Percy Jacks · 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

    Implement a streamlined DVT pathway directing suspected cases to radiology, initiating primary treatment before ultrasound, and ensuring positive and negative results receive appropriate follow-up.

    Verbatim wording from the response

    “The process of managing potential DVT patients has been streamlined and a definite pathway introduced. All GP referrals which suspected DVTs are referred direct to the Hospital's Radiology Department as per the attached protocol. It is incumbent on the GPs to commence their primary prior to an ultrasound scan being undertaken. Following their scan, if the result is positive, the patient is referred back to the A & E Department where they are reviewed by the on-call Physicians. There is a pre-printed letter that is completed by the on-call physicians to the GP with recommendations and this is also copied to the Anticoagulation Clinic. If the result of the scan is negative, the patient is referred back to their GP for further evaluation.”

    Source location

    2017-0329-Response
    Page 1 · response
    Published 2 December 2017

    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

    Record all suspected DVT referrals and follow up 48 hours later to confirm receipt of results.

    Verbatim wording from the response

    “We have discussed this in our practice meeting and have made the following changes.”

    Source location

    2017-0329-Response-by-Rhayader-Group-Practic
    Page 1 · response
    Published 2 December 2017

    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 how inspections assess timely information transfer between services, using policy, medicines and clinical expertise.

    Verbatim wording from the response

    “As a result of the concerns being brought to our attention we have taken the opportunity to review how CQC checks that information about patients being transferred between services happens in a timely manner and whether there is any more we as a regulator can do to prevent an incident such as this from happening in future.”

    Source location

    2017-0329-Response-by-Care-Quality-Commission
    Page 6 · response
    Published 2 December 2017

    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

    Revise and improve the wording of the Key Lines of Enquiry on information sharing during transfers between services.

    Verbatim wording from the response

    “We have revised and improved the wording of our Key Lines of Enquiry and from November 2017 inspectors will be considering the following two specific questions when they are reviewing the safety of a practice, instead of one being a prompt supporting the other: ‘When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?’ and ‘How well do the systems that manage information about people who use services support staff, carers and partner agencies to deliver safe care and treatment? (This includes coordination between different electronic and paper-based systems and appropriate access for staff to records.)’”

    Source location

    2017-0329-Response-by-Care-Quality-Commission
    Page 4 · response
    Published 2 December 2017

    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

    Have inspectors use two specific information-sharing questions when reviewing practice safety from November 2017.

    Verbatim wording from the response

    “We have revised and improved the wording of our Key Lines of Enquiry and from November 2017 inspectors will be considering the following two specific questions when they are reviewing the safety of a practice, instead of one being a prompt supporting the other: ‘When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?’ and ‘How well do the systems that manage information about people who use services support staff, carers and partner agencies to deliver safe care and treatment? (This includes coordination between different electronic and paper-based systems and appropriate access for staff to records.)’”

    Source location

    2017-0329-Response-by-Care-Quality-Commission
    Page 4 · response
    Published 2 December 2017

    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

    Welsh Clinical Portal access was considered sufficient for the GP to review the patient's A&E attendance outcome despite the discharge summary issue.

    Verbatim wording from the response

    “All Primary and Secondary Care Doctors have access to the Welsh Clinical Portal. This allows them to access test, radiology and documentation for a patient wherever the patient receives cares in Wales, regardless of geographical or organisational boundaries. See attached printout from the NHS Wales Informatics Service website which provides further information. Mr Jacks' GP would have had access to this and would have been able to review the outcome of his attendance at the A & E Department at Bronglais General Hospital on 6 February 2017.”

    Source location

    2017-0329-Response
    Page 2 · response
    Published 2 December 2017

    Open published response

  5. Berkshire

    AI-generated summary

    Mr George Arthur Cheese · 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 George Arthur Cheese, an 18-year-old man, was found hanging in woodland near his home on 9 April 2015. He had anxiety and depression with suicidal thoughts, and concerns were raised about the amount of Fluoxetine prescribed and the absence of a flag to limit repeat medication supplies.

    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 the amount of antidepressant medication prescribed to patients with suicidal thoughts

    Wider context from the report

    “(2) Mr Cheese was prescribed Fluoxetine anti-depressant medication on the 3rd November 2014 by a treating GP, following admitting to fleeting suicidal thoughts. He was reviewed by ████████ on 14th January 2015 when Mr Cheese described daily episodes of intense low mood with suicidal thoughts which included taking an overdose. This led to a reference to the Mental Health Team. At an appointment with the Practice’s Nurse Practitioner on 3rd February, Mr Cheese was prescribed 112 tablets of Fluoxetine. In the course of her evidence, ████████ stated that the Nurse Practitioner was probably just repeating the same prescription that the previous Doctor had issued to Mr Cheese but that she, ████████, would not have done that. (3) ████████ also acknowledged, in the course of her evidence, that there was no “flag” on Mr Cheese’s notes to alert treating Clinicians within the GP Practice to limit the amount of medication provided to Mr Cheese in view of his history. She acknowledged that a flag, in such circumstances, was good practice. (4) The concerns arising from the evidence are therefore the amount of medication prescribed to a patient who was known to be suffering from mental health issues and describing suicidal thoughts and a potential overdose and the fact that this was not being flagged to prevent large amounts of medication being provided to him as a matter of repeat prescription. ”

    Source location

    Mr George Arthur Cheese · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require GPs to conduct repeat-prescription issuance and depression reviews.

    Verbatim wording from the response

    “Shortly after George died the partners introduced the requirement for the issue of repeat prescriptions and depression reviews to be conducted by GPs only; receptionists are aware that patients with anxiety and depression cannot be seen by nurse practitioners. This policy has been circulated to all our GPs and nurses/nurse practitioners. The addition of a flag - or ‘major alert’ - on the front screen of the patient’s record is the responsibility of the GP who initially assesses or reviews the patient should they have concerns at any time. This could include receiving a letter from Talking Therapies expressing concern about a patient’s suicidal thoughts.”

    Source location

    2017-0179-Response-by-Woodley-Centre-Surgery
    Page 1 · response
    Published 4 August 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require the assessing or reviewing GP to add a major alert when concerned about a patient’s risk.

    Verbatim wording from the response

    “Shortly after George died the partners introduced the requirement for the issue of repeat prescriptions and depression reviews to be conducted by GPs only; receptionists are aware that patients with anxiety and depression cannot be seen by nurse practitioners. This policy has been circulated to all our GPs and nurses/nurse practitioners. The addition of a flag - or ‘major alert’ - on the front screen of the patient’s record is the responsibility of the GP who initially assesses or reviews the patient should they have concerns at any time. This could include receiving a letter from Talking Therapies expressing concern about a patient’s suicidal thoughts.”

    Source location

    2017-0179-Response-by-Woodley-Centre-Surgery
    Page 1 · response
    Published 4 August 2017

    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

    Discuss the significant event at the next clinical meeting.

    Verbatim wording from the response

    “I have written up the role of the clinicians including the issue of 112 capsules of fluoxetine to George on 2 occasions as a ‘significant event’ and will be discussing this at our next clinical meeting on Thursday 27th July. Analysis of significant events is a requirement of the CQC (Care Quality Commission) inspection to demonstrate that events that have been detrimental to patient care have been identified, discussed and lessons have been learnt with the aim of improving the quality of care. We have also arranged for a consultant psychiatrist from the local mental health team to talk about management of mental health disorders at our clinical meeting scheduled for Wednesday 23rd August.”

    Source location

    2017-0179-Response-by-Woodley-Centre-Surgery
    Page 1 · response
    Published 4 August 2017

    Open published response

  6. Birmingham and Solihull

    AI-generated summary

    Ahshiyah Bibi · 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

    Ahshiyah Bibi died at Birmingham Heartlands Hospital on 22 December 2016 after admission with reduced consciousness and acute renal failure. During her treatment, there was a delay in commencing treatment for high potassium and an insulin prescribing and dispensing error. The report identified concerns about missing blood gas results and the absence of a Trust-wide review or system to reduce the risk of similar errors.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to prevent inappropriate insulin prescribing for hyperkalaemia

    Wider context from the report

    “2. At 04:00 a drug error was made in the prescribing and dispensing of Actrapid insulin for hyperkalaemia: Mrs. Bibi was prescribed a 50 unit dose instead of a 10 unit dose, the error was identified when she had received 20 units and the infusion was stopped. The evidence of ████████ who prescribed the insulin was she knew the Trust’s protocol and standard treatment to be a dose of 10 units but made a mistake. It appears from investigations carried out by ████████ that the two members of the nursing staff who dispensed the dose did not check the dose. Professor Hanif, Consultant in Diabetes, gave independent expert evidence that in his view there is a risk of inappropriate prescribing of insulin in the management of hyperkalaemia because clinicians are more commonly called upon to prescribed a 50 unit does for Hyperglycaemia. Therefore in his opinion a system is required to avoid error in cases of hyperkalaemia. ████████ agreed that the fact she more commonly prescribes a 50 unit dose of insulin for hyperglycaemia probably did explain her error. ”

    Source location

    Ahshiyah Bibi · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Nottinghamshire

    AI-generated summary

    Kimberley Holden · 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

    Kimberley Holden, who had a chronic neurological condition and chronic pain, died from Oxycodone toxicity on 26 November 2014 after a dose significantly higher than intended was prescribed. The concerns included unsafe prescribing of controlled drugs and poorly coordinated management and prescribing between healthcare providers.

    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

    Unsafe prescribing of controlled drugs

    Wider context from the report

    “1. The continuing risk of unsafe prescribing of controlled drugs by the Ivy Grove Surgery, and the limited understanding of the duty to report serious prescribing incidents. ”

    Source location

    Kimberley Holden · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. South Yorkshire (Eastern)

    AI-generated summary

    Lyndsey Holt · 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

    Lyndsey Holt, who was 37 weeks pregnant, collapsed after a gastric ulcer perforated and caused catastrophic bleeding. She died the following morning after emergency surgery and resuscitation; concerns included the telephone prescribing of methadone without sufficient information, assessment, or early medical review, and the provision of a seven-day supply to a methadone-naïve patient.

    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 detail regarding drugs taken, usage frequency and dependence before methadone prescribing

    Wider context from the report

    “The circumstances in which the methadone was prescribed namely: (1) Doing so over the telephone with no face to face consultation. (2) Consequent lack of detail regarding: 2.1 the drugs being taken by Miss Holt 2.2 the frequency with which they were being taken 2.3 the degree if any, of her dependence 2.4 absence of assessment of any psychological issues (3) Providing a methadone naïve patient with a 7 day supply. (4) Lack of medical review during the initial phase. ”

    Source location

    Lyndsey Holt · 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

    Absence of assessment of psychological issues before methadone prescribing

    Wider context from the report

    “The circumstances in which the methadone was prescribed namely: (1) Doing so over the telephone with no face to face consultation. (2) Consequent lack of detail regarding: 2.1 the drugs being taken by Miss Holt 2.2 the frequency with which they were being taken 2.3 the degree if any, of her dependence 2.4 absence of assessment of any psychological issues (3) Providing a methadone naïve patient with a 7 day supply. (4) Lack of medical review during the initial phase. ”

    Source location

    Lyndsey Holt · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Birmingham and Solihull

    AI-generated summary

    Timothy Simon Jones · 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

    Timothy Simon Jones, who had Down syndrome, epilepsy and dementia and required PEG feeding, was admitted to hospital with breathing difficulties and aspiration pneumonia, was discharged and readmitted the same day, and died on 17 July 2016. Concerns included incomplete GP record keeping, unclear communication and documentation of requests for home visits, lack of GP clinical assessment despite deteriorating health and complex needs, a home-visit policy that did not address residents with complex chronic conditions, and antibiotic prescribing for aspiration pneumonia.

    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 the appropriate antibiotics for specific clinical situations

    Wider context from the report

    “5. The deceased was diagnosed with aspiration pneumonia when he was admitted to hospital. He was at high risk of aspiration pneumonia. I heard evidence that the best antibiotics for aspiration pneumonia are co-amoxiclav. The deceased was not prescribed these in the community he was given amoxicillin instead. Consideration needs to be given whether guidelines should be produced to clarify which antibiotics are required in specific situations. ”

    Source location

    Timothy Simon Jones · 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

    Ask the Birmingham and Area Antimicrobial Group to consider including aspiration pneumonia in local primary-care antimicrobial guidelines.

    Verbatim wording from the response

    “The Birmingham and Solihull Area Prescribing Committee has approved local antimicrobial guidelines which are promoted to practices. These guidelines are based on the PHE guidance for the management of common infections in Primary Care and are adapted for local use by the Birmingham and Area Antimicrobial Group (BAAG) which has representation from primary and secondary care across Birmingham. Neither the PHE guidelines nor the local version include a recommendation for aspiration pneumonia. The recommended antimicrobial therapy for community acquired pneumonia for adults is amoxicillin. In addition to the actions above we are asking the BAAG via our local microbiologist to consider the inclusion of aspiration pneumonia within the local version of the Primary Care Guidelines.”

    Source location

    2016-0421-Response-by-Solihull-Clinical-Commissioning-Group
    Page 2 · response
    Published 19 February 2017

    Open published response

  10. Brighton and Hove

    AI-generated summary

    Philip Richard David BREATNACH · 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

    Philip Richard David Breatnach's circumstances are referred to in the Record of Inquest. The concerns relate to online applications for medication, inadequate checking of answers and failure to contact his GP, and the prescribing of Dihydrocodeine by a prescriber who had not seen him, including concerns about the quantity, suitability for migraine, and dosing instructions. The inquest concluded with a finding of MISADVENTURE (DEPENDENCE ON DRUGS).

    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

    Excessive quantities of Dihydrocodeine prescribed

    Wider context from the report

    “(1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ”

    Source location

    Philip Richard David BREATNACH · 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

    Prescribing Dihydrocodeine for migraine

    Wider context from the report

    “(1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ”

    Source location

    Philip Richard David BREATNACH · 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 prescribe safe Dihydrocodeine dosing instructions

    Wider context from the report

    “(1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ”

    Source location

    Philip Richard David BREATNACH · 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 account for the potential diversion of Dihydrocodeine

    Wider context from the report

    “(1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ”

    Source location

    Philip Richard David BREATNACH · 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 assess a patient in person before prescribing Dihydrocodeine

    Wider context from the report

    “(1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did. (3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true. (4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice. (5) The amount of Dihydrocodeine prescribed appears to be excessive. (6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication. (7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed. (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did. (9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use. ”

    Source location

    Philip Richard David BREATNACH · 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

    Work with partner agencies to consolidate regulatory and professional guidance on online prescribing and medicine supply.

    Verbatim wording from the response

    “The group agreed to work together to assimilate current regulatory and professional guidance into one place so there is greater clarity regarding good practice in respect of online prescribing and supply of medicines giving particular guidance on medicines such as controlled drugs and antibiotics.”

    Source location

    2016-0330-Response-by-NHS-England
    Page 2 · response
    Published 18 September 2016

    Open published response

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