Recurring concern

Unreliable medication storage and access controls

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First reported 5 Feb 2019•Latest report 30 Dec 2019

Definition

What this concern includes

Includes failures in controls governing the storage location, environmental conditions, accessibility, guidance, staff awareness and availability of medicines when those controls are needed to preserve medicine safety or enable timely treatment, including refrigerated medicines and emergency antidote supplies.

Not included

  • Excludes prescribing, dispensing, administration, monitoring and supply failures where medication storage or immediate storage-related access is not the unsafe condition.
  • Excludes generic staff training, documentation or communication deficiencies unless they directly impair medication storage requirements or access.
  • Excludes storage of non-medicinal clinical equipment and supplies, such as NG tubes, unless the assertion explicitly concerns medication storage.
  • Excludes medication-security or unauthorised-access concerns where the issue is access control against misuse rather than correct storage conditions or timely clinical availability.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2019–2019

First to latest report issue date

Stated actions
0

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.

Bedfordshire Hospitals NHS Foundation Trust1
Department of Health and Social Care1
Greater Manchester Health and Social Care Partnership1
Greater Manchester Mental Health NHS Foundation Trust1
National Institute for Health and Care Excellence1

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. Manchester South

    AI-generated summary

    Maureen Waterfall · 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

    Maureen Waterfall fell at home on 12 July 2019 while taking the anticoagulant Edoxaban and sustained a head injury that led to a subdural haematoma. She died at Willow Wood Hospice on 26 July 2019. Concerns included the lack of a licensed specific antidote for Edoxaban, uncertainty about treatment effectiveness and timing, the absence of national guidance, and the storage of antidote supplies away from the resuscitation unit.

    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 national standard guidance for storage of anticoagulant antidote supplies

    Wider context from the report

    “3. I heard that there is no national standard guidance about the storage of supplies of anticoagulant antidote drugs. As a result, as in this case at Tameside General Hospital Accident and Emergency Department they were not kept at the resuscitation unit, but rather they were kept in the haematology department ”

    Source location

    Maureen Waterfall · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Unavailability of anticoagulant antidote supplies at the resuscitation unit

    Wider context from the report

    “3. I heard that there is no national standard guidance about the storage of supplies of anticoagulant antidote drugs. As a result, as in this case at Tameside General Hospital Accident and Emergency Department they were not kept at the resuscitation unit, but rather they were kept in the haematology department ”

    Source location

    Maureen Waterfall · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Bedfordshire and Luton

    AI-generated summary

    Gwyneth Ann EDWARDS · 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

    Gwyneth Ann EDWARDS was admitted to Bedford Hospital on 7 December 2017 and deteriorated after Hydrocortisone and Desmopressin were not dispensed. She developed severe hypernatraemia and died on 14 December 2017 while receiving end-of-life care; the stated cause of death included bronchopneumonia and hypernatraemia, with failure to administer Desmopressin and maintain appropriate fluids. Concerns included gaps in weekend transfer arrangements, NEWS scores not being acted upon, an unverified Mobile Medic review marked complete, staff unfamiliarity with Desmopressin storage, and staffing pressures affecting monitoring and record-keeping.

    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 ensure staff know that desmopressin tablets are kept in the fridge

    Wider context from the report

    “(4) Desmopressin tablets are kept in the fridge, but the staff were not familiar with the drug to know that. There appears to be no warning on the drug charts that this is the case. ”

    Source location

    Gwyneth Ann EDWARDS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026