PFD report

Dorothy Joan ROBINSON · Prevention of Future Deaths report

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Issued 13 Aug 2014•Avon

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
1

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

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Concerns raised1

  1. Failure to implement a Trust-wide system preventing prescription errors due to intolerance, reaction or allergy
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.5

  1. Action

    Strengthen non-electronic prescribing safeguards by requiring allergy documentation, pharmacy verification, staff reminders and education, and nurses’ pre-administration checks.

    Stated by Royal United Hospitals Bath NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2014.
  2. Action

    Continue learning from hospitals implementing electronic prescribing, including Oxford University Hospitals NHS Trust, to support safe phased development.

    Stated by Royal United Hospitals Bath NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2014.
  3. Action

    Assess and develop a Trust-wide electronic prescribing system that records adverse drug reactions and requires completion before prescribing or dispensing.

    Stated by Royal United Hospitals Bath NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2014.

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 implement a Trust-wide system preventing prescription errors due to intolerance, reaction or allergy

Wider context from the report

“During the inquest I heard evidence that there remains a risk of a prescribing error despite the steps taken by RUH to date. I have been advised that there is only one way to help prevent this and that is through the electronic prescribing system referred to in the Action Plan to the Root Cause Analysis. I was not told an exact date when the system will be introduced only that there was an understanding that it may take up to two years. I would like to receive reassurance from the RUH as to the exact steps that are being taken in relation to installing this system or indeed any other system which can help prevent a prescription error. I was advised that the millennium system is not proposed to be used in this way Therefore in summary please advise of the steps planned to be taken to prevent a prescription error across the whole of the Trust in all areas of medicine due to a previous intolerance/reaction/allergy. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Strengthen non-electronic prescribing safeguards by requiring allergy documentation, pharmacy verification, staff reminders and education, and nurses’ pre-administration checks.

Verbatim wording from the response

“Pending the development of e-prescribing at the RUH, which may well take more than two years to be fully implemented, we have strengthened processes to mitigate the risk of a drug being administered to a patient who is known to be intolerant of it. Presently, our non-electronic prescribing systems incorporate the need to record such an intolerance. Patients attend the Royal United Hospital as in-patients, out-patients and as day case patients. If patients require a medicine in any of these settings, the pharmacy will not supply that medicine against a prescription unless the allergy / adverse reaction box has been completed on the medication chart. Through internal reminders and education we continue to emphasise this absolute rule. In addition, nurses check the allergy status of in-patients before administration of medicines.”

Source location

2014-0374-Response-by-Royal-United-Hospital-Bath
Page 1 · response
Published 13 August 2014

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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

Continue learning from hospitals implementing electronic prescribing, including Oxford University Hospitals NHS Trust, to support safe phased development.

Verbatim wording from the response

“Currently there is limited experience of e-prescribing systems in the NHS across the country. What experience hospitals have had has highlighted the need for a cautious approach with time spent testing and refining to avoid unintended consequences. The RUH Information Technology and clinical teams have close working relationships with other hospitals that are implementing e-prescribing and continue to learn from those leading this improvement. Of particular note is our work with the Oxford University Hospitals NHS Trust who use the same base system as the RUH and are just in the process of a phased roll out of e-prescribing.”

Source location

2014-0374-Response-by-Royal-United-Hospital-Bath
Page 1 · response
Published 13 August 2014

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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

Assess and develop a Trust-wide electronic prescribing system that records adverse drug reactions and requires completion before prescribing or dispensing.

Verbatim wording from the response

“Recommendation 4 of the investigation report written by ████████ suggests the introduction of a Trust-wide electronic prescribing system that readily makes available information about previous adverse drug reactions at the time of prescribing and dispensing of medications. Further, that the system could mandate completion of adverse drug reaction information before a prescription is accepted on the system. In the ensuing action time line the report notes that this is currently being assessed, but implementation is likely to take at least two years.”

Source location

2014-0374-Response-by-Royal-United-Hospital-Bath
Page 1 · response
Published 13 August 2014

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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

Launch the electronic prescribing module for patients discharged with medication, mandating allergy and adverse-reaction entries in GP discharge letters.

Verbatim wording from the response

“An electronic prescribing module for patients being discharged with medication from the RUH has been developed and will be launched in March 2015. An earlier system was tested Trust wide in 2013 but required revision to capture all the safety features, an example of how testing and refining of e-prescribing is essential to avoid solving one problem whilst creating another. This system will also mandate the entry of allergies/adverse reactions in the discharge letter that goes to GPs. Currently this is done manually if an adverse reaction occurs in hospital.”

Source location

2014-0374-Response-by-Royal-United-Hospital-Bath
Page 2 · response
Published 13 August 2014

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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

Develop ARIA electronic prescribing coverage for all Oncology and Haematology in-patients and out-patients receiving complex medicine regimens.

Verbatim wording from the response

“In specific specialties, such as Oncology and Haematology there is an electronic prescribing system that mandates the entry of an allergy / adverse reaction at the point of prescribing. This system is called ARIA and is referred to in the investigation report. Investment has been made to develop ARIA to ensure that it covers all out-patients and in-patients receiving the complex medicines regimens prescribed in Oncology and Haematology. This will take a further 12 – 18 months to complete.”

Source location

2014-0374-Response-by-Royal-United-Hospital-Bath
Page 2 · response
Published 13 August 2014

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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.1

  1. 1

    Invest £18 million in a replacement patient administration system to support development of electronic clinical systems.

    Stated by Royal United Hospitals Bath NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 August 2014.

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

Invest £18 million in a replacement patient administration system to support development of electronic clinical systems.

Verbatim wording from the response

“The Trust continues to expand its use of information technology in support of safer clinical care and has recently committed to investing £18m in a replacement patient administration system, the foundation stone from which we can fully develop electronic clinical systems.”

Source location

2014-0374-Response-by-Royal-United-Hospital-Bath
Page 1 · response
Published 13 August 2014

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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