Recurring concern

Inadequate communication of opioid toxicity risks

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First reported 28 Aug 2019•Latest report 31 Mar 2025

Definition

What this concern includes

Includes failures of controls specifically intended to communicate, explain or reinforce opioid-toxicity risks to patients, carers or relevant clinicians, including risks from lost tolerance after abstinence, renal accumulation, combined opioid use and related overdose or respiratory-depression hazards.

Not included

Excludes general medication counselling or patient-information deficiencies where opioid toxicity is not the material safety concern.
Excludes opioid prescribing, dosage, quantity, administration or monitoring failures where communication of opioid-toxicity risks is not the deficient control.
Excludes treatment failures after opioid toxicity or overdose has occurred unless the assertion also identifies inadequate opioid-risk communication.
Excludes warnings about non-opioid medicines or unrelated medication hazards.

Reports: 4
Individual concerns: 4
Date range: 2019–2025
Stated actions: 2

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Barts Health NHS Trust1

Central and North West London NHS Foundation Trust1

County Durham and Darlington NHS Foundation Trust1

Home Office1

Langley Health Centre1

Mitie1

Mitie Care And Custody Limited1

Recipient name withheld1

Royal Free Hospital1

Tees, Esk and Wear Valleys NHS Foundation Trust1

the Hillingdon Hospitals NHS Foundation Trust1

Wife of the deceased1

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.

31 Mar2025
Inner North London
Concerns raised1
1. Lack of awareness of opioid toxicity and accumulation risks in patients with kidney impairment or failure
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Update and distribute local adult opioid-toxicity management guidelines, including interim advice based on national best-practice guidance.
  Stated by Royal Free London NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Expert review concluded that the patient was unlikely to have experienced opioid toxicity, contrary to the concern raised.
  Stated by Royal Free London NHS Foundation TrustDisputes the concern
AI-generated summary

Abu RAHMAN · 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

Abu Rahman, aged 88, suffered a traumatic fall causing a fractured hip and underwent hemi-arthroplasty before deteriorating with pneumonia on a background of end stage renal failure. Concerns included delays in obtaining Naloxone when supplies ran out and limited awareness of opioid toxicity or accumulation in patients with kidney impairment or failure.

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 opioid toxicity and accumulation risks in patients with kidney impairment or failure
Wider context from the report
“Firstly, I heard evidence from the family that nursing staff were frequently unable to administer Naloxone as it had run out. They had to obtain more Naloxone from the pharmacy, which led to delays for “hours and hours” on multiple occasions. Secondly, I heard evidence concerning a lack of awareness or appreciation concerning the risk of opioid toxicity / accumulation in patients with kidney impairment/failure, even where the “correct” dose may have been given. I am concerned that if there is no proper or properly implemented system for obtaining medication in a timely manner, and limited awareness of the matters canvassed above, then this gives rise to a risk of future deaths. ”
Source location
Abu RAHMAN · 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 and distribute local adult opioid-toxicity management guidelines, including interim advice based on national best-practice guidance.

Verbatim wording from the response
“It is recognised that the process of initiating Naloxone in Dr Rahman’s case was not in line with available best practice guidance. Bolus injections of Naloxone are recommended, to assess the response from the patient and an infusion is commenced thereafter with the dose titrated according to the amount required to achieve an initial response. It is acknowledged that awareness of this process should be shared amongst the medical team in the Acute”

Source location
Response from Royal Free Hospital
Page 1 · response
Published 1 April 2025
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
Expert review concluded that the patient was unlikely to have experienced opioid toxicity, contrary to the concern raised.

Verbatim wording from the response
“Considering Dr Rahman’s diagnosis of end stage renal failure the half-life (the time it takes for the amount of a drug’s active substance in your body to reduce by half) of oxycodone in patients increases by up to 1.7 times compared to patients with normal renal function. A review by a Consultant Nephrologist and Lead Renal Pharmacist confirmed that the final dose of Oxycodone administered at 10:04 on 11 November 2024 would have been expected to have been metabolised that afternoon. From the information gathered, following a review of the patient’s medical records with input from an expert panel, it was concluded that the patient in this case was unlikely to have opioid toxicity.”

Source location
Response from Royal Free Hospital
Page 3 · response
Published 1 April 2025
Open published response
4 Jun2024
County Durham and Darlington
Concerns raised1
1. Lack of a protocol or policy for warning patients about acute respiratory depression and death risks from alcohol or drug misuse after administration of the drug
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review and update the acute alcohol withdrawal policy to include patient advice, using stakeholder input, and obtain approval by September 2024.
  Stated by County Durham and Darlington NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  The chlordiazepoxide concern is for CDDFT to address, and CDDFT has reportedly responded.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustRedirects responsibility
AI-generated summary

Andrew James Naylor · 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

Andrew James Naylor was found deceased on 11 October 2022 in Durham City, the day after discharge from hospital following treatment for a drug overdose and alcohol withdrawal. The report identified concerns about inadequate warnings of the risks associated with combining the administered drug with alcohol or drugs, poor communication between services, and insufficient consideration of his homelessness, discharge safety, and available support. The inquest concluded that he died from the combined central nervous system depressant actions of alcohol and two drugs, with cumulative failures contributing more than minimally 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
Lack of a protocol or policy for warning patients about acute respiratory depression and death risks from alcohol or drug misuse after administration of the drug
Wider context from the report
“(1) There is no specific protocol or policy in place to ensure that patients are warned of the acute risk of respiratory depression and death following administration of the drug ████████ should they drink alcohol or misuse drugs. ”
Source location
Andrew James Naylor · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and update the acute alcohol withdrawal policy to include patient advice, using stakeholder input, and obtain approval by September 2024.

Verbatim wording from the response
“The Trust has a Management of Acute Alcohol Withdrawal Policy which has been extended until September 2024 to enable the Organisation to explore the most appropriate, and safest, way to include the suggestion raised by yourself. This will require careful stakeholder”

Source location
Response from CDDFT
Page 1 · response
Published 30 July 2024
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
The chlordiazepoxide concern is for CDDFT to address, and CDDFT has reportedly responded.

Verbatim wording from the response
“I am writing to you in response to the Prevention of Future Death (PFD) Report issued to Tees, Esk and Wear Valleys NHS Foundation Trust ("TEWV", or "the Trust") on 04.06.2024 following the inquest touching the death of Andrew Naylor. I note that the PFD Report issued has been directed to both TEWV and County Durham and Darlington NHS Foundation Trust (CDDFT), on the basis you have concerns in respect of both organisations. I have not responded to point 5(1) as this issue relating to Chlordiazepoxide, appears to be for CDDFT to respond to and I am assured that they have responded.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust
Page 1 · response
Published 30 July 2024
Open published response
23 Oct2019
Inner North London
Concerns raised1
1. Lack of written advice on the risks of combining multiple opioids
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Kenneth John Daly · 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

Kenneth John Daly, who had chronic pain and anxiety and was prescribed multiple medications, was found dead at home on 4 December 2018. The inquest concluded that his death was drug related, involving multi-drug toxicity, after he overdosed on Morphine, Dihydrocodeine and Codeine alongside Pregabalin and benzodiazepine medication. Concerns included unclear guidance about using multiple opioid medications together and the absence of tailored written advice for Mr Daly.

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 written advice on the risks of combining multiple opioids
Wider context from the report
“1) In oral evidence, the Consultant stated that no other opioids were to be taken once Morphine Sulphate and Co-Codamol had been prescribed but that prescribing of Pregabalin could continue. She set out her advice in a letter to Mr Daly’s GP dated 11 July 2018. The letter clearly stated that Fentanyl and Tapentadol should be stopped and Morphine sulphate (MST) 60mg started. The advice regarding the prescribing of pain relieving medications other than Fentanyl and Tapentadol is less clear. In relation to Dihydrocodeine and Tramadol it is stated that “He can continue using the Dihydrocodeine and very rarely Tramadol until he sees you for his next prescription. Together with the MST, I would recommend to allow him Co-Codamol 30/500mg 2 tablets up to four times a day...”. Following receipt of the letter, Tramadol and Dihydrocodeine continued to be issued by the GP practice albeit at lower quantities than previously prescribed. The GP did not seek any further guidance regarding the advice given in the letter of 11 July 2018 from the Consultant. 2) Mr Daly was a patient that was known to adjust his pain medication without seeking guidance from his GP. Whilst Mr Daly was copied in to the letter sent to his GP on 11 July 2018, he was not given any written guidance regarding his pain relief and the use of other medications (such as benzodiazepines) that was tailored to his needs as a patient. Specifically, he was not given any written advice regarding the risks of using multiple opioid medications in combination. ”
Source location
Kenneth John Daly · Prevention of Future Deaths report
Page 4 · concerns
Open source report
28 Aug2019
London (West)
Concerns raised1
1. Failure to apply renal impairment information in codeine overdose assessment
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Amir Siman-Tov · 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

Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.

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 apply renal impairment information in codeine overdose assessment
Wider context from the report
“6. Mr Siman-Tov was taken to the Hillingdon Hospital in the late morning following his overdose on the 16ᵗʰ February 2016. At the Hillingdon Hospital an assessment, examination and blood tests were taken. The blood tests indicated renal impairment. An information system TOXBASE is used in emergency departments to provide assistance to clinicians. Toxbase indicates that in renal impairment greater care must be taken in cases of codeine overdose. This was missed. ”
Source location
Amir Siman-Tov · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of awareness of opioid toxicity and accumulation risks in patients with kidney impairment or failure

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of a protocol or policy for warning patients about acute respiratory depression and death risks from alcohol or drug misuse after administration of the drug

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of written advice on the risks of combining multiple opioids

Concerns raised1

Failure to apply renal impairment information in codeine overdose assessment

Actions described in response 1

Respondent positions 1

Actions described in response 1

Respondent positions 1