PFD report

Paolino AMICO · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 17 Nov 2025•Essex

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.

View original report
Concerns
19

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
15

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised19

  1. Failure to provide clear oxygen-therapy discharge planning and referral information
    Part of recurring concern: Unreliable hospital discharge processes
  2. Failure to review the patient before prescribing a controlled drug
    Part of recurring concern: Unsafe medication prescribing
  3. Failure to consider or plan alternative pain management during opioid overdose treatment
    Part of recurring concern: Failure to provide timely and adequate pain reliefPart of recurring concern: Failure to reassess treatment options when clinically indicatedPart of recurring concern: Unreliable clinical management of medication overdose and toxicity
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.10

  1. Action

    Operate networks for Controlled Drugs Accountable Officers and Medication Safety Officers to receive and spread learning from medication errors.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
  2. Action

    Provide guidance and tools to NHS Trusts for learning from patient safety incidents and improving controlled-drug safety.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
  3. Action

    Provide restorative clinical supervision and professional nurse advocate learning on controlled drugs, communication, challenge and escalation.

    Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 provide clear oxygen-therapy discharge planning and referral information

Wider context from the report

“(1) The consultant required a discharge plan for oxygen therapy to be in place before Mr Amico could go home. The hospital discharge plan and medications were confusing and the referral for oxygen therapy requirement was unclear, and the PAT testing for the machine was out of date. Paramedics advised the family that the oxygen provided on Mr Amico’s discharge was low flow and was not meeting his oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew equipment. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

Open source report

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 review the patient before prescribing a controlled drug

Wider context from the report

“(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June. a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain. b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST. c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug. d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management. e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

Open source report

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 consider or plan alternative pain management during opioid overdose treatment

Wider context from the report

“(6) Mr Amico morphine overdose was partially treated: a. There was an immediate response to Naloxone but the opioid reversal for overdose was not in accordance with British National Formulary guidelines or with an NHS England alert previously issued. b. There was no consideration or plan for alternative pain management in a patient who had been receiving morphine pain relief as part of his treatment plan for cancer. c. Mr Amico suffered acute withdrawal syndrome and family complained about his suffering to hospital staff that they stated was not ameliorated. An emergency call would have triggered the attendance of an Anaesthetist who could have given advice on opioid reversal in a palliative patient. Princess Alexandra Hospital & NHS England ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate pain relief; Failure to reassess treatment options when clinically indicated; Unreliable clinical management of medication overdose and toxicity.

Open source report

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 accurately record medication administration

Wider context from the report

“(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June. a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain. b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST. c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug. d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management. e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning. ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

Open source report

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

Non-mandatory medicines-administration refresher training for nurses

Wider context from the report

“(8) Medicines administration refresher training for nurses is not mandatory and the Trust in reviewing this case has not followed a local recommendation from senior nurses for this to be included. ”

Is this part of a recurring concern?

Yes — Failure to ensure mandatory safety training is completed before safety-critical work; Unsafe medication administration.

Open source report

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 escalate medication concerns to appropriately senior clinicians

Wider context from the report

“(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June. a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain. b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST. c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug. d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management. e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning. ”

Is this part of a recurring concern?

Yes — Failure to escalate significant clinical concerns to appropriately senior clinicians; Failure to provide effective senior clinical oversight of patient care.

Open source report

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 make an emergency call for an unresponsive patient

Wider context from the report

“(3) Mr Amico’s NEWS score increased, and an emergency call was not put out on 11 June when it was established that Mr Amico was unresponsive even to pain from 03:00 hours . ”

Is this part of a recurring concern?

Yes — Unreliable emergency response to patient collapse.

Open source report

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 of medicines-administration training to support recognition of inappropriate MST prescribing

Wider context from the report

“(7) Multiple nurses were involved in morphine administration and all had completed their original training outside of the UK and had undertaken a Trust medicines administration training that should have recognised that the prescription of MST 4 times a day was not appropriate. Mr Amico received 6 doses of MST in less than 24 hours instead of 2. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 administer MST at the prescribed frequency

Wider context from the report

“(7) Multiple nurses were involved in morphine administration and all had completed their original training outside of the UK and had undertaken a Trust medicines administration training that should have recognised that the prescription of MST 4 times a day was not appropriate. Mr Amico received 6 doses of MST in less than 24 hours instead of 2. ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

Open source report

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 provide opioid reversal in accordance with applicable guidance

Wider context from the report

“(6) Mr Amico morphine overdose was partially treated: a. There was an immediate response to Naloxone but the opioid reversal for overdose was not in accordance with British National Formulary guidelines or with an NHS England alert previously issued. b. There was no consideration or plan for alternative pain management in a patient who had been receiving morphine pain relief as part of his treatment plan for cancer. c. Mr Amico suffered acute withdrawal syndrome and family complained about his suffering to hospital staff that they stated was not ameliorated. An emergency call would have triggered the attendance of an Anaesthetist who could have given advice on opioid reversal in a palliative patient. Princess Alexandra Hospital & NHS England ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 administer prescribed medication

Wider context from the report

“(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June. a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain. b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST. c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug. d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management. e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning. ”

Is this part of a recurring concern?

Yes — Failure to provide required medication promptly when clinically needed; Unsafe medication administration.

Open source report

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 identify prescription errors and prior doses during controlled-drug checks

Wider context from the report

“(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June. a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain. b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST. c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug. d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management. e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning. ”

Is this part of a recurring concern?

Yes — Unreliable detection and monitoring of prescription errors.

Open source report

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 the local recommendation to include mandatory medicines-administration refresher training

Wider context from the report

“(8) Medicines administration refresher training for nurses is not mandatory and the Trust in reviewing this case has not followed a local recommendation from senior nurses for this to be included. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 scrutinise prescribed medication and medication-system information

Wider context from the report

“(2) Mr Amico did not receive his prescribed medications during his second admissions when he was readmitted to hospital on 9 June. a. On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s prescribed medications and increased liquid oral morphine sulphate 10 mg in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 hours with slow released morphine sulphate (MST) continued 2 times daily. Trust staff did not administer any morphine to Mr Amico although he and his family were raising concerns about his high level of pain. b. The family was informed incorrectly that medications had not been prescribed. On the morning of 10 June, the family were given permission by a nurse to dispense from Mr Amico’s own supply of medications that he had brought to the hospital due to his level of pain. This was not accurately recorded in Mr Amico’s record. Mr Amico took his prescribed morning dose of MST. c. On 10 June the nurse in Accident & Emergency did not escalate to the nurse in charge or a senior doctor that she could not locate the doctor allocated to Mr Amico and instead approached a foundation year 1 doctor to prescribe pain relief for Mr Amico. The nurse informed the doctor who was junior and very busy that the frequency of the morphine needed to be increased for Mr Amico. The doctor did not escalate the matter and did not review Mr Amico before prescribing a controlled drug. d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9 June or on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management. e. Mr Amico then moved to a ward. Multiple nurses were involved in checking and administering a controlled drug morphine sulphate slow release (MST) on 5 separate occasions between 10 and 11 June 2024 and did not raise concerns about the potential for a prescription error or note that Mr Amico had already received 1 dose of MST that morning. ”

Is this part of a recurring concern?

Yes — Unreliable medication dosage verification and communication; Unreliable medication reconciliation across care transitions; Unsafe medication prescribing.

Open source report

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 communicate overnight deterioration and family medication concerns to the on-call doctor

Wider context from the report

“(4) The on-call doctor was called approximately one hour after Mr Amico’s NEWS score was found to be 10 and arrived at 07:50, this was not an emergency call. The on-call doctor had not been informed of: a. the deterioration in Mr Amico’s presentation during the night b. that the family had informed nursing staff of their concerns Mr Amico had been given the wrong medication when he was noted to be unresponsive at approximately 03:00 hours, that should have immediately raised concerns about an overdose of MST. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond to acute clinical deterioration; Unreliable communication of patient-care information between clinical staff.

Open source report

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 provide oxygen flow meeting patient requirements at discharge

Wider context from the report

“(1) The consultant required a discharge plan for oxygen therapy to be in place before Mr Amico could go home. The hospital discharge plan and medications were confusing and the referral for oxygen therapy requirement was unclear, and the PAT testing for the machine was out of date. Paramedics advised the family that the oxygen provided on Mr Amico’s discharge was low flow and was not meeting his oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew equipment. ”

Is this part of a recurring concern?

Yes — Unsafe provision of oxygen therapy.

Open source report

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

Delay and inappropriate escalation of a high NEWS score

Wider context from the report

“(4) The on-call doctor was called approximately one hour after Mr Amico’s NEWS score was found to be 10 and arrived at 07:50, this was not an emergency call. The on-call doctor had not been informed of: a. the deterioration in Mr Amico’s presentation during the night b. that the family had informed nursing staff of their concerns Mr Amico had been given the wrong medication when he was noted to be unresponsive at approximately 03:00 hours, that should have immediately raised concerns about an overdose of MST. ”

Is this part of a recurring concern?

Yes — Failure to escalate significant clinical concerns to appropriately senior clinicians; Unreliable clinical Early Warning Score systems for deterioration; Unreliable escalation of abnormal clinical observations.

Open source report

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 make an emergency call after escalation of concerns

Wider context from the report

“(5) The on-call doctor escalated concerns immediately but not emergency call was put out. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Out-of-date PAT testing for oxygen equipment

Wider context from the report

“(1) The consultant required a discharge plan for oxygen therapy to be in place before Mr Amico could go home. The hospital discharge plan and medications were confusing and the referral for oxygen therapy requirement was unclear, and the PAT testing for the machine was out of date. Paramedics advised the family that the oxygen provided on Mr Amico’s discharge was low flow and was not meeting his oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew equipment. ”

Is this part of a recurring concern?

Yes — Failure to ensure essential clinical equipment and supplies are available and serviceable; Unreliable PAT testing and safety assurance for electrical equipment.

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

Operate networks for Controlled Drugs Accountable Officers and Medication Safety Officers to receive and spread learning from medication errors.

Verbatim wording from the response

“NHS England offers support to providers to improve the safe use of controlled drugs. NHS Trusts must appoint a Controlled Drugs Accountable Officer and a Medication Safety Officer. Their remits differ however both have a duty to ensure the safe use of opioids in their organisations. NHS England operates networks for both groups to receive and spread the learning from errors. We also offer guidance and tools to enable NHS Trusts to effectively learn from patient safety incidents through the Patient Safety Incident Response Framework. We note that the Patient Safety Incident Response Plan for the Princess Alexandra Hospital includes workstreams to improve safety in ED, in Medicines management, controlled drugs and medicines reconciliation.”

Source location

Response from NHS England
Page 3 · response
Published 19 November 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

Provide guidance and tools to NHS Trusts for learning from patient safety incidents and improving controlled-drug safety.

Verbatim wording from the response

“NHS England offers support to providers to improve the safe use of controlled drugs. NHS Trusts must appoint a Controlled Drugs Accountable Officer and a Medication Safety Officer. Their remits differ however both have a duty to ensure the safe use of opioids in their organisations. NHS England operates networks for both groups to receive and spread the learning from errors. We also offer guidance and tools to enable NHS Trusts to effectively learn from patient safety incidents through the Patient Safety Incident Response Framework. We note that the Patient Safety Incident Response Plan for the Princess Alexandra Hospital includes workstreams to improve safety in ED, in Medicines management, controlled drugs and medicines reconciliation.”

Source location

Response from NHS England
Page 3 · response
Published 19 November 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

Provide restorative clinical supervision and professional nurse advocate learning on controlled drugs, communication, challenge and escalation.

Verbatim wording from the response

“Restorative clinical supervision took place in June 2024, which was a reflective discussion with special emphasis on how to manage challenging prescribers and how to have an effective professional discussion when in doubt of management plan, and how to escalate higher if still in doubt.”

Source location

Response from Princess Alexandra Hospital
Page 5 · response
Published 19 November 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

Review the training framework, including whether management training should become mandatory and whether refresher training should be tracked and monitored.

Verbatim wording from the response

“courses are not systematically required or monitored. Senior nursing staff previously recommended refresher training to be included as part of ongoing competency assurance; however, this recommendation has not yet been implemented.”

Source location

Response from Princess Alexandra Hospital
Page 9 · response
Published 19 November 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

Share opioid reversal guidance through palliative-care educational events and hold collaborative opioid-learning events with the integrated care system.

Verbatim wording from the response

“The BNF highlights that doses used in acute opioid/opiate overdose may NOT be appropriate for the management of opioid/opiate induced respiratory depression and sedation in those receiving palliative care and in chronic opioid/opiate use. The recommended dose for adults in post-operative respiratory depression and for palliative care and chronic opioid/opiate use by intravenous injection is 100 to 200 micrograms (1.5 to 3 micrograms/kg). If the response is inadequate, give subsequent dose of 100 micrograms every two minutes. Even where doses are given as recommended, there is still a need for careful monitoring of vital observations and maintaining or restoring pain relief.”

Source location

Response from Princess Alexandra Hospital
Page 7 · response
Published 19 November 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

Clarify morphine product names and predefine twice-daily frequency for modified-release morphine prescriptions in the electronic prescribing system.

Verbatim wording from the response

“In addition, we have recognised there is a huge variation in morphine formulation and type and have made the naming of products clearer. For example, MST is noted as ‘Morphine MODIFIED RELEASE 12 HOURLY tablets’ on the system. We have also pre-defined the frequency as twice a day.”

Source location

Response from Princess Alexandra Hospital
Page 5 · response
Published 19 November 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

Introduce a patients’ own controlled drug book in the emergency department to record and account for patients’ controlled medicines.

Verbatim wording from the response

“The emergency department do not have a stock of MST. At the time there was not a patients’ own controlled drug book to record controlled medication. The administration was recorded on JAC, the Trust electronic medication system that his family had given his regular prescribed medication.”

Source location

Response from Princess Alexandra Hospital
Page 3 · response
Published 19 November 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

Review the Trust’s naloxone policy following the incident.

Verbatim wording from the response

“The Trust also has a policy on Naloxone, which was reviewed following this incident. see Appendix 2.”

Source location

Response from Princess Alexandra Hospital
Page 7 · response
Published 19 November 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

Remove the option to modify existing prescriptions in the electronic prescribing system, requiring cancellation or discontinuation and reordering with clinical warnings.

Verbatim wording from the response

“d. Neither the nurse nor the doctor sufficiently scrutinised the medication prescribed on 9th June on the Trust system that would have shown the correct medications. This led to a prescription error being made with MST being increased from 2 times daily to 4 times daily. Mr Amico was not referred for pain management.”

Source location

Response from Princess Alexandra Hospital
Page 4 · response
Published 19 November 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

Include the emergency department escalation process in area-specific orientation for nurses redeployed from their base wards.

Verbatim wording from the response

“A Multi-Disciplinary After-Action Review meeting was held, including staff involved in the incident. This identified learnings and actions to be taken. It established that the ED nurses looking after Mr Amico had been redeployed from another ward so were not fully aware of the ED escalation process that occurs in the emergency department.”

Source location

Response from Princess Alexandra Hospital
Page 4 · response
Published 19 November 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

The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.

Verbatim wording from the response

“The Princess Alexandra Hospital NHS Trust will be providing their own response to this Report, however, the Hertfordshire & West Essex ICB have advised NHS England of the Trust’s governance arrangements and actions being taken to address the concerns raised. It is understood that the Trust’s Patient Safety Group (PSG) has active oversight of several of the areas highlighted in the Report, particularly medicines safety, recognition of deterioration, and incident learning.”

Source location

Response from NHS England
Page 4 · response
Published 19 November 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

Education and training alone would not sufficiently mitigate recurrence; systems improvements and mechanisms are also required.

Verbatim wording from the response

“The NICE medicines optimisation guidance NG 5 (2015) referenced above recommends that organisations support healthcare professionals through training and education to ensure safe prescribing, dispensing and administration. In this specific case, education and training alone would not prevent these types of safety system issues and would not be sufficient to mitigate the risk of reoccurrence. Systems improvements and mechanisms will need to be implemented to ensure lessons are learnt and that the current organisational and systems factors and processes highlighted in this case are addressed, to ensure the safe and effective checking and administration of medications. This has been substantiated by safety research and incident analysis.”

Source location

Response from NHS England
Page 4 · response
Published 19 November 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

The prescribed home oxygen level was appropriate because it reflected an evidence-based respiratory assessment at discharge.

Verbatim wording from the response

“The comments from the paramedics relate to Mr Amico’s oxygen requirement at the time they assessed him. At the time of discharge the respiratory nurse had assessed Mr Amico and his oxygen requirements based on an evidence-based assessment and the appropriate level of oxygen based on those observations was prescribed and arranged for him at home.”

Source location

Response from Princess Alexandra Hospital
Page 3 · response
Published 19 November 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

An emergency call was not required because appropriate care was initiated promptly after the raised NEWS score.

Verbatim wording from the response

“5. The on-call doctor escalated concerns immediately but no emergency call was put out.”

Source location

Response from Princess Alexandra Hospital
Page 7 · response
Published 19 November 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

The records do not corroborate that the patient was unresponsive from 3:00 am, and no concerns were raised then.

Verbatim wording from the response

“It is noted that the documentation from the doctor who reviewed Mr Amico suggests that Mr Amico had been unresponsive since 3 am however the Trust is unable to ascertain where this information came from as the observation and medication records do not corroborate that finding.”

Source location

Response from Princess Alexandra Hospital
Page 6 · response
Published 19 November 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

The oxygen concentrators did not require portable appliance testing because there was no legal requirement for supplier testing.

Verbatim wording from the response

“Portable Appliance Testing (PAT) is a process used to ensure the safety of electrical appliances and equipment. The head of patient services at BOC has informed our operations team that they do not PAT test concentrators as there is no legal requirement for them to be PAT tested.”

Source location

Response from Princess Alexandra Hospital
Page 2 · response
Published 19 November 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.5

  1. 1

    Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning nationally and regionally across the NHS.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
  2. 2

    Hold monthly meetings between ward matrons, the chief pharmacist and EPMA lead to monitor medication incident themes.

    Stated by the Princess Alexandra Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2025.
  3. 3

    Conduct a multidisciplinary after-action review of the medication administration incident and identify learning and actions.

    Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
  4. 4

    Maintain mandatory Medical Gases training for staff requiring it, with completion recorded on staff training profiles.

    Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
  5. 5

    Share medication-safety learning across divisions and Trustwide through governance meetings and the learning-from-deaths group.

    Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 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

Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning nationally and regionally across the NHS.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Paolino, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 5 · response
Published 19 November 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

Hold monthly meetings between ward matrons, the chief pharmacist and EPMA lead to monitor medication incident themes.

Verbatim wording from the response

“Monthly ongoing meetings with ward matron and chief pharmacist and EPMA lead to review all incident themes for ongoing monitoring.”

Source location

Response from Princess Alexandra Hospital
Page 5 · response
Published 19 November 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

Conduct a multidisciplinary after-action review of the medication administration incident and identify learning and actions.

Verbatim wording from the response

“A Multi-Disciplinary After-Action Review meeting was held, including staff involved in the incident. This identified learnings and actions to be taken. It established that the ED nurses looking after Mr Amico had been redeployed from another ward so were not fully aware of the ED escalation process that occurs in the emergency department.”

Source location

Response from Princess Alexandra Hospital
Page 4 · response
Published 19 November 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

Maintain mandatory Medical Gases training for staff requiring it, with completion recorded on staff training profiles.

Verbatim wording from the response

“In 2023 PAHT confirmed Medical Gases training could be mandatory. Currently 2216 staff including 630 staff in Medical and Dental staff group have Medical Gases on their profiles as Mandatory training.”

Source location

Response from Princess Alexandra Hospital
Page 9 · response
Published 19 November 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

Share medication-safety learning across divisions and Trustwide through governance meetings and the learning-from-deaths group.

Verbatim wording from the response

“Learning was shared across the Divisions and Trustwide by the Patient Safety and Quality (PSQ) Lead Nurse and discussed at Medicine Divisional Governance meeting and learning from deaths group.”

Source location

Response from Princess Alexandra Hospital
Page 6 · response
Published 19 November 2025

Open published response
Back to top

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