This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On 20 January 2022 I commenced an investigation into the death of Paula Doreen Hughes, aged 55 years. The investigation concluded at the end of the inquest on 22 July 2025. The conclusion of the inquest was Paula Doreen Hughes died on 1 January 2022 at Queen Elizabeth Hospital, Woolwich, London. The medical cause of death was recorded as
1a Acute (fulminant) hepatic failure
1b Paracetamol Overdose
2 Ischaemic heart disease, urinary tract infection, diabetes mellitus and excess alcohol consumption I concluded that the death with the following narrative:
A medication error resulting in an unintended therapeutic excess of paracetamol contributed to by failure to recognise it and administer timely treatment to mitigate the risk of liver toxicity
Circumstances of the death
Paula Hughes had been admitted to Queen Elizabeth Hospital on 6 January 2022 having suffered a fractured humerus following a fall the previous evening. Between 6 and 8 January 2022 she received paracetamol in excess of the recommended dose largely as a consequence of paracetamol being inadvertently prescribed addition to co-codamol, a paracetamol containing drug, on 7 January. Pharmacy review failed to pick up the concurrent prescription and both drugs were administered together on 3 or 4 occasions until the duplicate prescription was deleted at around 14.30 on 8 January. Despite a deterioration in her condition from around midday on 8 January, it was not recognised that Mrs Hughes had received an overdose of paracetamol until the morning of 9 January, by which time she had been admitted to intensive care in fulminating acute liver failure. As a consequence, she did not receive timely treatment with n-acetyl cysteine which would have mitigated the toxic effects of paracetamol on her liver.
Coroner’s concerns
1. In respect of preventing concurrent prescriptions of paracetamol containing drugs and otherwise preventing prescribing errors resulting in therapeutic excess of paracetamol (NHSE, RPS, Cerner, MHRA, LGT)
(1) NHSE, RPS, Cerner, MHRA
I consider that the risk of concurrent prescriptions of paracetamol containing drugs is of wider national concern.
The Cerner prescribing system offers a duplicate checking functionality that is not a standard feature. It is hard stop and can be overridden and was not adopted by the LGT when the system was introduced. All the healthcare professionals were aware that co-codamol contained paracetamol and should not be prescribed with paracetamol. However, the 2 prescribing doctors failed to recognise that Mrs Hughes was already prescribed a paracetamol containing drug. 2 nurses failed to recognise they were administering 2 paracetamol containing drugs. A pharmacist failed to identify the concurrent prescriptions during reconciliation.
(2) LGT
LGT’s response to the incident was swift and commendable. A hard stop was introduced to the electronic prescribing system which eliminated concurrent prescriptions of paracetamol containing drugs. Further refinements of the system significantly reduced therapeutic excesses of paracetamol based on weight, which had been identified as an issue when investigating Mrs Hughes’ death. However, it is my understanding that consideration is being given to changing the electronic record and prescribing system. My concern is that during any move to a new system, the safety nets introduced by the Trust will be diluted or lost.
2. Management of therapeutic excess if it has not been prevented (LGT)
This issue has arisen from the finding that once the concurrent prescription had been identified, there had no attempt to consider whether there had been a therapeutic excess and whether Mrs Hughes had suffered harm. The Trust’s response to the incident focused on prevention. It did not consider the adequacy of the clinical response once the overdose had been identified. The Trust relies on information sharing of learning from incidents and thereafter places reliance on individual clinical practice. I received no evidence of a robust process for ensuring a consistent clinical response to the management of therapeutic excess and the potential for toxicity.
3. The assessment of the ACVPU score (LGT, RCP, NHSE)
This concern has arisen out of the fact that Mrs Hughes was scored as alert when she was confused. Confusion would have added a score of 3 to her NEWS2 score and would have resulted in an earlier escalation of her condition. I heard that confusion is not always easy to identify and that the signs can be subtle.
(1) LGT
The Trust provided training materials relating to detection and management of deteriorating patients. There was minimal guidance on how to accurately assess the ACVPU score and the confusion element in particular. There remains a tangible risk that the ACVPU score will continue to be assessed inconsistently, with new episodes of confusion continuing to be missed.
(2) NHSE, RCP
I consider that consistent and accurate assessment of the ACVPU element of the NEWS2 score is likely to a matter of wider concern. This concern is being brought to the attention of NHSE and the RCP as I consider that they have the power to support healthcare professionals to ensure consistent and accurate scoring of confusion.
4. Mechanism for recording over the counter medications taken prior to attendance at the Emergency Department (LGT)
This concern has arisen out of my finding that Mrs Hughes had taken an over the counter (OTC) drug containing paracetamol before her admission to hospital but that this had not been recorded as part of her medication history. The Trust’s Medicines Reconciliation Policy requires that patients should be asked about OTCs. The Trust relies on individual clinical practice. There is no mechanism to ensure that pre-admission OTCs are consistently recorded such that the risk of therapeutic excess of paracetamol (or other drugs available OTC) in those circumstances continues to exist.
5. Trust approach to mitigating against confirmation bias and encouraging professional curiosity (LGT)
Confirmation bias and a lack of professional curiosity were significant features in Mrs Hughes’ being administered two paracetamol containing drugs at the same time and in not investigating whether she had received a therapeutic excess and suffered consequential harm. I have found that the Trust does not have robust mechanism for mitigating against confirmation bias and encouraging professional curiosity.
6. Trust policy on managing virtual patient reviews (LGT)
This concern has arisen out of the fact that Mrs Hughes had been reviewed virtually rather than face to face a resident doctor on the morning before she became unwell. The Trust has no guidance or policy on virtual reviews. I was told that this is a matter of clinical judgment. The absence of any guidance to help a still relatively inexperienced resident doctor decide when they can dispense with a face-to-face review is a circumstance that creates a risk that future deaths may occur.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised7
Failure to prevent concurrent prescriptions of paracetamol-containing drugs
Continue reviewing and monitoring Trust-client awareness of duplicate-prescription and paracetamol overdose alert functionality.
Stated byOracle Corporation UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Continue discussing potential software or configuration enhancements with clients, including their appropriateness and workflow impact.
Stated byOracle Corporation UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Continue working with Trust clients to inform and educate them about available alert functionality.
Stated byOracle Corporation UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Discuss safeguards against paracetamol dosing incidents with Trust clients through quarterly meetings.
Stated byOracle Corporation UK LimitedStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Introduce the UK Administration Alert Notification and explain its triggers, operation and implementation options to Trusts through a Special Interest Group meeting.
Stated byOracle Corporation UK LimitedStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Present updates to the Administration Alert Notification, including patient-weight-based maximum-dose calculations, to Trust clients.
Stated byOracle Corporation UK LimitedStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Continue augmenting the content and functionality of Millennium alert notifications, including overdose-related alerts.
Stated byOracle Corporation UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Complete a detailed review of Millennium’s duplicate-prescription and paracetamol overdose alert functionality.
Stated byOracle Corporation UK LimitedStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Deliver ward-staff refresher training on recognising deterioration, escalation and accurate ACVPU assessment.
Stated byLewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Edit internal professional standards locally and work with virtual-ward providers to improve safety around virtual reviews.
Stated byLewisham and Greenwich NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Review and revise the Adult Deteriorating Patient Policy to incorporate relevant guidance and clear ACVPU assessment instructions.
Stated byLewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Develop and provide staff with a clinical guideline for managing paracetamol overdose and therapeutic excess.
Stated byLewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Create a Medicines Reconciliation Quick Reference Guide for Emergency Department staff covering information sources and over-the-counter medicine prompts.
Stated byLewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Seek assurance that Epic will implement iCare paracetamol safety features when introduced across the three Trusts.
Stated byLewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Maintain electronic prescribing alerts preventing duplicate or excessive paracetamol prescribing and administration.
Stated byLewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Develop guidance for safe virtual patient reviews using national guidance.
Stated byLewisham and Greenwich NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Disseminate virtual-review safety expectations, risks and escalation routes through patient-safety bulletins.
Stated byLewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Present the case for patient-safety discussion and learning about confirmation bias.
Stated byLewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Increase deteriorating-patient training completion across relevant clinical areas during 2026/27 compared with the 2025 baseline.
Stated byLewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Oversee and monitor compliance and effectiveness of new virtual-review processes through quality governance structures.
Stated byLewisham and Greenwich NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Amend Emergency Department and ambulance handover documentation to prompt recording of over-the-counter medicines.
Stated byLewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Review and update deteriorating-patient training with clearer ACVPU guidance, case scenarios and recognition of subtle confusion.
Stated byLewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Assess options for adding over-the-counter medicine prompts and fields to iCare pharmacy medication-history processes.
Stated byLewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Disseminate learning and required changes from the recently reviewed internal professional standards through the leadership exercise.
Stated byLewisham and Greenwich NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Review medicines-reconciliation policies and checklists to clarify discussion and documentation of over-the-counter medicines and ambulance handover information.
Stated byLewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Share learning from the case about confirmation bias and professional curiosity through Grand Round and medical-student teaching.
Stated byLewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Review escalation processes for advice-giving and requesting senior input or face-to-face assessment.
Stated byLewisham and Greenwich NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.9
Position
National training to ensure consistent ACVPU assessment is best addressed by the Royal College of Physicians.
Stated byNHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHSE is responsible for incorporating incident learning into commissioning the ePRaSE prescribing system.
Building electronic prescribing alerts requires national oversight to coordinate work with secondary-care system suppliers.
Stated byRoyal Pharmaceutical SocietyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
No evidence has been identified that the software contains a defect or deficiency relevant to duplicate paracetamol prescribing.
Stated byOracle Corporation UK LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing prescribing and administration alert functionality is considered appropriate and functioning as designed, so further alert-notification code development is unnecessary.
Stated byOracle Corporation UK LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The client decides whether to adopt particular code or configuration enhancements, taking account of clinical and commercial considerations.
Stated byOracle Corporation UK LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Face-to-face review is not always necessary where adequate information is shared and an escalation process exists.
Stated byLewisham and Greenwich NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Requiring every virtual review to be face to face is considered unsustainable and impossible.
Stated byLewisham and Greenwich NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Other statements in published responses
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2
1
Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across national and regional NHS structures.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
2
Consider raising awareness of paracetamol prescribing risks through future communications and engagement with the wider pharmacy sector.
Stated byRoyal Pharmaceutical SocietyStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
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