Recurring concern

Inadequate clinician training for safe opioid prescribing and dosing

First to latest report 11 Jun 2014 — 28 Sep 2020

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
2

What this concern includes

Includes failures of training, education, refresher provision or competence assurance specifically concerning safe opioid prescribing or dosing, including morphine, fentanyl, codeine and comparable opioid analgesics, for newly qualified, locum, GP or other clinicians.

What is not included
  • Excludes unsafe opioid prescribing decisions where no deficiency in opioid-specific training or competence assurance is identified.
  • Excludes opioid supply, custody, dispensing, administration, monitoring or treatment failures that are not directly tied to clinician training for safe opioid prescribing or dosing.
  • Excludes generic medication training or general clinical education without a material opioid-prescribing or opioid-dosing focus.
  • Excludes training concerning substance-misuse treatment or opioid dependence where safe opioid prescribing or dosing is not the shared condition.

Reports and published responses 3 reports

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

  1. Essex

    AI-generated summary

    June Patricia Margaret PARLOUR · 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

    June Parlour was an inpatient with disseminated terminal cancer when she received morphine doses exceeding national and hospital guidelines. Her condition deteriorated, and she later died of opiate toxicity; the overdose significantly hastened her death. Concerns included staff awareness of morphine guidance, inaccurate hospital guidance and incident reporting, education and auditing for doctors, unclear prescribing instructions, and communication and escalation failures between staff.

    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

    Inadequate education on safe morphine doses for newly qualified and locum doctors

    Wider context from the report

    “(3) I am concerned as to the adequacy of education re safe morphine doses that newly qualified doctors and locum doctors receive, and how this is audited. ”

    Source location

    June Patricia Margaret PARLOUR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Update junior doctor induction with high-risk medication training and provide additional training for higher-grade doctors in training.

    Verbatim wording from the response

    “To capture Doctors in training, the Medical Directors of Education have engaged and communicated the guidelines, and updated the junior doctor induction programme to ensure this is embedded in practice moving forward.”

    Source location

    2020-0186-Response-from-East-Suffolk-and-North-Essex_Redacted.pdf
    Page 1 · response
    Published 23 November 2020

    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

    Update locum and agency staff induction and monitor completion through the Education Team.

    Verbatim wording from the response

    “We have updated our locum and agency staff induction, which includes signposting to the relevant documents on the intranet and on the Medusa system. All locum and agency staff, in conjunction with the local ward team complete an induction form which is subsequently sent to the Education Team who monitor adherence with the induction process.”

    Source location

    2020-0186-Response-from-East-Suffolk-and-North-Essex_Redacted.pdf
    Page 2 · response
    Published 23 November 2020

    Open published response

  2. Brighton and Hove

    AI-generated summary

    Mr. Isaac BAHAR · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure locum staff awareness of analgesia guidance for patients with Chronic Kidney Disease

    Wider context from the report

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

    Source location

    Mr. Isaac BAHAR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The medication error was not caused or contributed to by inadequate knowledge, education, or locum staff selection and induction.

    Verbatim wording from the response

    “The Trust’s lead pharmacist in patient safety carried out a detailed investigation of this matter. She found no evidence that there was a failure in knowledge or education, or any failure in selection or induction of locum staff, which caused or contributed to the medication being prescribed outside the Trust’s recommended analgesia guidance. The British National Formulary (BNF) makes it clear that codeine and other opioid analgesics should be avoided or used with caution at reduced doses in patients with renal impairment.”

    Source location

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

    Open published response

  3. London (West)

    AI-generated summary

    June Lilian Rose · 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

    June Lilian Rose was bed bound and in deteriorating health when she was prescribed fentanyl patches at an excessive dose, which were applied and replaced before the error was discovered. She later died at home on 14 August 2012; the recorded cause of death included bilateral pneumonia, Alzheimer’s disease and fentanyl toxicity. The principal concern was the lack of mandatory national training or refresher training for GPs on prescribing fentanyl and similar morphine-based pain relief medications.

    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 mandatory and regular refresher training for GPs in prescribing fentanyl and similar morphine-based pain relief medications

    Wider context from the report

    “While the prescribing doctor recognised the an error was made in prescribing the fentanyl patches at that level, it became apparent at the inquest that there appears to be little training of GPs on a national level in the prescription of this and other similar morphine based pain relief medications and consequently, a lack of familiarity with the dosage required or appropriate. I heard evidence that although this particular surgery had sought to take steps to prevent this event from reoccurring, I remain concerned that there is no mandatory training or regular refresher training on a national level in the prescribing of these kinds of drugs. ”

    Source location

    June Lilian Rose · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

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Data last updated 7 September 2026