Recipient

Boehringer Ingelheim LimitedIncludes reports addressed to a minister or senior office-holder acting for this organisation.

First report 16 Aug 2019•Latest report 16 Aug 2019

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
4

Across all linked responses

Stated actions
7

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found
7stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Boehringer Ingelheim Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: Mr Uday Bose, Chief Executive, Boehringer Ingelheim Limited.

    West Sussex

    AI-generated summary

    George Benjamin Rimmer · 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

    George Benjamin Rimmer was found deceased at home on 25 October 2018 after being prescribed Oramorph for pain following decompression surgery. The concerns included taking the medicine directly from the bottle rather than measuring doses, possible lack of counselling about exceeding the prescribed dose, and insufficient warnings about excess or cumulative dosing.

    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. The report was sent to Boehringer Ingelheim Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of bottle warnings about unmeasured or excessive dosing

    Wider context from the report

    “(1) Mr Rimmer was known to swig out of the bottle rather than take a measured dose as many patient do; (2) Mr Rimmer self medicated as required; (3) Mr Rimmer’s GP did not recall advising him of the possible consequences of exceeding the prescribed dose. (4) There was no evidence to show that anyone had counselled Mr Rimmer with regards to the use of this drug. (5) The leaflet that comes with the bottle does not provide a sufficient warning of the dangers of taking an excess dose. (6) There is no mention of the dangers of drinking from the bottle and not measuring the dose. (7) There is no warning on the bottle to act as a reminder of the dangers of taking an excess dose or of the cumulative effect of taking more than the prescribed amount. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Boehringer Ingelheim Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to counsel medication users on the use and risks of exceeding the prescribed dose

    Wider context from the report

    “(1) Mr Rimmer was known to swig out of the bottle rather than take a measured dose as many patient do; (2) Mr Rimmer self medicated as required; (3) Mr Rimmer’s GP did not recall advising him of the possible consequences of exceeding the prescribed dose. (4) There was no evidence to show that anyone had counselled Mr Rimmer with regards to the use of this drug. (5) The leaflet that comes with the bottle does not provide a sufficient warning of the dangers of taking an excess dose. (6) There is no mention of the dangers of drinking from the bottle and not measuring the dose. (7) There is no warning on the bottle to act as a reminder of the dangers of taking an excess dose or of the cumulative effect of taking more than the prescribed amount. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Boehringer Ingelheim Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Unmeasured dosing from the medication bottle

    Wider context from the report

    “(1) Mr Rimmer was known to swig out of the bottle rather than take a measured dose as many patient do; (2) Mr Rimmer self medicated as required; (3) Mr Rimmer’s GP did not recall advising him of the possible consequences of exceeding the prescribed dose. (4) There was no evidence to show that anyone had counselled Mr Rimmer with regards to the use of this drug. (5) The leaflet that comes with the bottle does not provide a sufficient warning of the dangers of taking an excess dose. (6) There is no mention of the dangers of drinking from the bottle and not measuring the dose. (7) There is no warning on the bottle to act as a reminder of the dangers of taking an excess dose or of the cumulative effect of taking more than the prescribed amount. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Boehringer Ingelheim Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient leaflet warnings about taking an excess dose

    Wider context from the report

    “(1) Mr Rimmer was known to swig out of the bottle rather than take a measured dose as many patient do; (2) Mr Rimmer self medicated as required; (3) Mr Rimmer’s GP did not recall advising him of the possible consequences of exceeding the prescribed dose. (4) There was no evidence to show that anyone had counselled Mr Rimmer with regards to the use of this drug. (5) The leaflet that comes with the bottle does not provide a sufficient warning of the dangers of taking an excess dose. (6) There is no mention of the dangers of drinking from the bottle and not measuring the dose. (7) There is no warning on the bottle to act as a reminder of the dangers of taking an excess dose or of the cumulative effect of taking more than the prescribed amount. ”
    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 MHRA approval to strengthen and embolden the prescriber-direction warning on the Oramorph bottle label.

    Verbatim wording from the response

    “However, we propose to strengthen and emphasise the wording on both the bottle label and carton label:”

    Source location

    2019-0269-Response-by-Boehringer-Ingelheim
    Page 8 · response
    Published 18 October 2019

    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

    Request MHRA approval to add an explicit warning against drinking Oramorph directly from the bottle and describe overdose risks in the patient information leaflet.

    Verbatim wording from the response

    “However, we will propose to the MHRA that we include within the ‘HOW TO TAKE ORAMORPH ORAL SOLUTION’ section the following statement (or words to that effect to be agreed with the MHRA):”

    Source location

    2019-0269-Response-by-Boehringer-Ingelheim
    Page 7 · response
    Published 18 October 2019

    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 dosing instructions and approved labelling were considered sufficiently clear despite lacking an explicit warning against drinking directly from the bottle.

    Verbatim wording from the response

    “Whilst there is no explicit warning in the PIL not to drink directly from the bottle, the wording of the ‘HOW TO TAKE ORAMORPH ORAL SOLUTION’ is also consistent with other oral morphine solutions (ref 9,10) available in the UK. These also provide specific instructions about measuring the correct dose but, like Oramorph®, they do not have an explicit warning not to drink directly from the bottle.”

    Source location

    2019-0269-Response-by-Boehringer-Ingelheim
    Page 7 · response
    Published 18 October 2019

    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

    Proposed changes to the leaflet, bottle label, and carton require review and approval by the MHRA and HPRA.

    Verbatim wording from the response

    “Please be advised that any proposed additions and amendments to the PIL, bottle and outer carton labelling will need to be reviewed and approved by both the MHRA (UK) and the Healthcare and Products Regulatory Agency (HPRA) in Ireland, since we maintain a joint pack for both countries.”

    Source location

    2019-0269-Response-by-Boehringer-Ingelheim
    Page 9 · response
    Published 18 October 2019

    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 existing Patient Information Leaflet sufficiently warns about excess-dose symptoms, risks, required medical help, and possible death, so no further action was taken.

    Verbatim wording from the response

    “Conclusion 4 We feel the wording of the PIL (both current and June 2015 version) is sufficient to warn the patient of the need to take only the dose the doctor has prescribed, to seek medical help if too much is taken and the warning signs/symptoms and associated risks of taking too much and therefore we took no further action to this matter of concern.”

    Source location

    2019-0269-Response-by-Boehringer-Ingelheim
    Page 6 · response
    Published 18 October 2019

    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 bottle and carton wording was considered sufficiently clear and compliant with statutory requirements, despite a proposal to strengthen and emphasise it.

    Verbatim wording from the response

    “Please be aware the space to include additional information on the bottle label is limited and guidance to the patient is covered in detail in the PIL (see response to matter of concern 4 confirming that the warning symptoms/signs and risks of an excess dose, including death, are clearly stated).”

    Source location

    2019-0269-Response-by-Boehringer-Ingelheim
    Page 8 · response
    Published 18 October 2019

    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

    Prescribing clinicians and other healthcare professionals are responsible for explaining dosing, risks, and consequences of exceeding prescribed doses.

    Verbatim wording from the response

    “We view this matter of concern as more pertinent to Mr Rimmer’s prescribing clinician and other healthcare professionals.”

    Source location

    2019-0269-Response-by-Boehringer-Ingelheim
    Page 3 · response
    Published 18 October 2019

    Open published response
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
43%57%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026