PFD report

Jacqueline Anne CARREY · Prevention of Future Deaths report

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Issued 26 Oct 2023•Milton Keynes

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
4

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. Failure to flag potential medication-use risks to staff before discharge
    Part of recurring concern: Unreliable communication of discharge medication information to care staff
  2. Lack of clear recording of potential medication-abuse risks in patient medical records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
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.2

  1. Action

    Review the electronic health record for proportionate additional safety measures affecting discharge medication processes.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 November 2023.
  2. Action

    Introduce a coded limited-supply question that triggers prominent alerts and directs doctors and pharmacists to review the medication history before discharge prescribing or dispensing.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 November 2023.

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 flag potential medication-use risks to staff before discharge

Wider context from the report

“There may not have been a clear indication on the patients medical record about the potential risk of ████████ abuse, or for the risk to be flagged up to members of staff before discharge. This oversight raises serious questions about the hospital's processes and procedures for managing ████████ medication and patient records. I strongly urge the hospital to undertake a comprehensive review of the procedures concerning the distribution of ████████ medication. It is imperative that the hospital ensures that the potential risks and warnings are clearly marked on the patient's medical record and that all staff are made aware of any potential concerns regarding ████████ use. I believe that a thorough review of your procedures and the implementation of more robust protocols can protect the well being of patients and prevent future similar deaths. ”

Is this part of a recurring concern?

Yes — Unreliable communication of discharge medication information to care staff.

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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

Lack of clear recording of potential medication-abuse risks in patient medical records

Wider context from the report

“There may not have been a clear indication on the patients medical record about the potential risk of ████████ abuse, or for the risk to be flagged up to members of staff before discharge. This oversight raises serious questions about the hospital's processes and procedures for managing ████████ medication and patient records. I strongly urge the hospital to undertake a comprehensive review of the procedures concerning the distribution of ████████ medication. It is imperative that the hospital ensures that the potential risks and warnings are clearly marked on the patient's medical record and that all staff are made aware of any potential concerns regarding ████████ use. I believe that a thorough review of your procedures and the implementation of more robust protocols can protect the well being of patients and prevent future similar deaths. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Review the electronic health record for proportionate additional safety measures affecting discharge medication processes.

Verbatim wording from the response

“In addition to using Mrs Carrey’s case for awareness raising and education within the broad pharmacy team, we have reviewed our EHR to determine whether additional safety steps can be incorporated in such a way as they do not negatively impact the timeliness of high-volume processes in a disproportionate way.”

Source location

Response from Milton Keynes University Hospital
Page 3 · response
Published 1 November 2023

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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

Introduce a coded limited-supply question that triggers prominent alerts and directs doctors and pharmacists to review the medication history before discharge prescribing or dispensing.

Verbatim wording from the response

“We have been able to incorporate new measures which – at their core – codify information / recommendations around the restriction of medicines supplied at discharge (i.e., exceptions to the contractual 14-day supply expectation). The ‘Pharmacy Medication History Form’ now includes the question ‘Does this patient get a limited supply in community’, requiring a ‘yes’ or ‘no’ answer. The user can still add free text narrative but the fact of selecting ‘yes’ in response to this question fires specific actions downstream when clinicians are looking to progress the patient’s discharge.”

Source location

Response from Milton Keynes University Hospital
Page 4 · response
Published 1 November 2023

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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.2

  1. 1

    Share learning from Mrs Carrey’s case with Oracle Cerner for dissemination to other NHS clients and international consideration.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 November 2023.
  2. 2

    Raise awareness and provide education to the pharmacy team using Mrs Carrey’s case.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 November 2023.

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 learning from Mrs Carrey’s case with Oracle Cerner for dissemination to other NHS clients and international consideration.

Verbatim wording from the response

“Workflows within Electronic Health Records (EHRs) are relatively standardised by supplier (rather than being bespoke to individual healthcare providers). We shall share our learning from Mrs Carrey’s case with Oracle Cerner (global supplier of our EHR), both such that it can be shared with other UK NHS clients but also considered internationally.”

Source location

Response from Milton Keynes University Hospital
Page 4 · response
Published 1 November 2023

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

Raise awareness and provide education to the pharmacy team using Mrs Carrey’s case.

Verbatim wording from the response

“In addition to using Mrs Carrey’s case for awareness raising and education within the broad pharmacy team, we have reviewed our EHR to determine whether additional safety steps can be incorporated in such a way as they do not negatively impact the timeliness of high-volume processes in a disproportionate way.”

Source location

Response from Milton Keynes University Hospital
Page 3 · response
Published 1 November 2023

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