PFD report

Abu RAHMAN · Prevention of Future Deaths report

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Issued 31 Mar 2025•Inner North London

Report record

Published report and response evidence

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.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Lack of awareness of opioid toxicity and accumulation risks in patients with kidney impairment or failure
    Part of recurring concern: Failure to identify clinically significant medication risksPart of recurring concern: Inadequate communication of opioid toxicity risks
  2. Failure to ensure timely availability of Naloxone
    Part of recurring concern: Failure to ensure naloxone is available and usable for opioid overdose emergenciesPart of recurring concern: Failure to provide required medication promptly when clinically neededPart of recurring concern: Unreliable access to clinically required medication during supply shortages
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Increase ward 8 North Naloxone stock from two to three boxes and audit stocking consistency.

    Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 April 2025.
  2. 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 plannedThe respondent said that this action was planned when they made their response on 1 April 2025.
  3. Action

    Deliver two weeks of safety-huddle sessions on accessing and replenishing Naloxone, including out-of-hours arrangements.

    Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  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 concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Failure to identify clinically significant medication risks; Inadequate communication of opioid toxicity risks.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to ensure timely availability of Naloxone

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. ”

Is this part of a recurring concern?

Yes — Failure to ensure naloxone is available and usable for opioid overdose emergencies; Failure to provide required medication promptly when clinically needed; Unreliable access to clinically required medication during supply shortages.

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

Increase ward 8 North Naloxone stock from two to three boxes and audit stocking consistency.

Verbatim wording from the response

“Clarity on the process of accessing Naloxone, including out of hours, should stock need replenishing will be shared at daily huddles for two weeks. In addition, pharmacy will be increasing the stock level on 8 North ward to reduce the likelihood of it not being immediately available. Stock levels have been increased from 2 boxes to 3 boxes which under expected usage levels provides a sufficient supply for more than 24 hours.”

Source location

Response from Royal Free Hospital
Page 2 · response
Published 1 April 2025

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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

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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

Deliver two weeks of safety-huddle sessions on accessing and replenishing Naloxone, including out-of-hours arrangements.

Verbatim wording from the response

“Clarity on the process of accessing Naloxone, including out of hours, should stock need replenishing will be shared at daily huddles for two weeks. In addition, pharmacy will be increasing the stock level on 8 North ward to reduce the likelihood of it not being immediately available. Stock levels have been increased from 2 boxes to 3 boxes which under expected usage levels provides a sufficient supply for more than 24 hours.”

Source location

Response from Royal Free Hospital
Page 2 · 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

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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

Access to Naloxone on ward 8 North was not disrupted; unusually high usage caused the delay in administration.

Verbatim wording from the response

“Access to Naloxone during Dr Rahman’s time on 8 North was not reported to be disrupted and his medication chart records that it was administered to him between 24 minutes and 1 hour following the prescription being made, despite the significant quantity that was used. It was concluded that this was a highly unusual circumstance, in which Dr Rahman was receiving ongoing infusions, requiring an unusually large quantity of Naloxone, as a result impacting the time to administer.”

Source location

Response from Royal Free Hospital
Page 2 · response
Published 1 April 2025

Open published response

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.3

  1. 1

    Develop a new electronic prescribing process to support clinicians and improve opioid-prescribing safety.

    Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 April 2025.
  2. 2

    Monitor adherence to the ongoing improvement plans through divisional and Trust-level quality and safety governance.

    Stated by Royal Free London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 April 2025.
  3. 3

    Assess and enact national MHRA opioid-prescribing advice through medicines governance committees.

    Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 April 2025.

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

Develop a new electronic prescribing process to support clinicians and improve opioid-prescribing safety.

Verbatim wording from the response

“Dr Rahman’s analgesia was prescribed in line with the new national advice issued via the MHRA regarding the use of opioids for the relief of post-operative pain. This advice was assessed through the Drugs and Therapeutics Committee and Medicines Safety Committee and enacted rapidly in advance of Dr Rahman’s admission. In addition, a new prescribing process has been developed for the EPR system to support prescribing clinicians and improve patient safety.”

Source location

Response from Royal Free Hospital
Page 3 · response
Published 1 April 2025

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

Monitor adherence to the ongoing improvement plans through divisional and Trust-level quality and safety governance.

Verbatim wording from the response

“The Trust is committed to learning from Dr Rahman’s tragic death and continuously improving patient safety. We will actively monitor adherence to the ongoing improvement plans and the Trust’s action plan is set out below. This will be monitored by the Acute Medicine, Emergency Department and Elderly Care (AMEDEC) Divisional Quality & Safety Board and the Clinical Performance and Patient Safety Committee.”

Source location

Response from Royal Free Hospital
Page 3 · response
Published 1 April 2025

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

Assess and enact national MHRA opioid-prescribing advice through medicines governance committees.

Verbatim wording from the response

“Dr Rahman’s analgesia was prescribed in line with the new national advice issued via the MHRA regarding the use of opioids for the relief of post-operative pain. This advice was assessed through the Drugs and Therapeutics Committee and Medicines Safety Committee and enacted rapidly in advance of Dr Rahman’s admission. In addition, a new prescribing process has been developed for the EPR system to support prescribing clinicians and improve patient safety.”

Source location

Response from Royal Free Hospital
Page 3 · response
Published 1 April 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026