PFD report

Robert Tom Duke SIMPSON · Prevention of Future Deaths report

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Issued 12 Aug 2025•Birmingham and Solihull

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
7

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 provide patients with the correct medication
  2. Failure to ensure availability and escalation of necessary prescribed medication
    Part of recurring concern: Failure to provide required medication promptly when clinically neededPart of recurring concern: Unsafe medication administration
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 induction and Medicines Management training on missed doses, time-critical medicines, escalation, and staff accountability for medicines administration.

    Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2025.
  2. Action

    Undertake spot-check assessments of registered nurses’ discharge-medicines practice and share outcomes and learning through monthly clinical assurance meetings.

    Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2025.
  3. Action

    Monitor compliance with medicines standards through weekly local assessments and monthly hospital, medication-safety, and group governance reporting until practice improvement is demonstrated.

    Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2025.

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

  1. Position

    UHB Pharmacy could not have prevented the missed doses because they occurred outside normal hours and Fidaxomicin was available through emergency drug cupboards.

    Stated by University Hospitals Birmingham NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant 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 patients with the correct medication

Wider context from the report

“1. It was accepted by the Trust that the deceased had been provided and discharged with medication (gabapentin) that did not belong to him and had missed two doses of antibiotics (fidaxomin) due to the drug being out of stock, which had not been communicated to or escalated to treating clinicians. 2. In evidence the Trust were unable to confirm whether the issues set out in 1. above sat solely with the nursing team or also involved pharmacy. 3. Whilst evidence was given in relation to the discharge nurse having undertaken reflection and a focus group being set up to explore improvements with discharge and planning there was no evidence as to how the wrong medication was provided to the deceased and whether this was a discharge only issue or also an issue with allocation and distribution of medication by pharmacy or by ward staff. 4. There was no evidence to explain how the deceased missed two doses of antibiotics due to the drug being out of stock, why treating clinicians were not informed or why an alternative antibiotic was not administered in its place. The Trust were unable to talk to what, if any, systems were in place to ensure that patients were not left without necessary medication. 5. I am concerned that there may still be a risk to life of patients within the trust if they are provided with the wrong medication or miss necessary doses of prescribed medication. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 availability and escalation of necessary prescribed medication

Wider context from the report

“1. It was accepted by the Trust that the deceased had been provided and discharged with medication (gabapentin) that did not belong to him and had missed two doses of antibiotics (fidaxomin) due to the drug being out of stock, which had not been communicated to or escalated to treating clinicians. 2. In evidence the Trust were unable to confirm whether the issues set out in 1. above sat solely with the nursing team or also involved pharmacy. 3. Whilst evidence was given in relation to the discharge nurse having undertaken reflection and a focus group being set up to explore improvements with discharge and planning there was no evidence as to how the wrong medication was provided to the deceased and whether this was a discharge only issue or also an issue with allocation and distribution of medication by pharmacy or by ward staff. 4. There was no evidence to explain how the deceased missed two doses of antibiotics due to the drug being out of stock, why treating clinicians were not informed or why an alternative antibiotic was not administered in its place. The Trust were unable to talk to what, if any, systems were in place to ensure that patients were not left without necessary medication. 5. I am concerned that there may still be a risk to life of patients within the trust if they are provided with the wrong medication or miss necessary doses of prescribed medication. ”

Is this part of a recurring concern?

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

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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 induction and Medicines Management training on missed doses, time-critical medicines, escalation, and staff accountability for medicines administration.

Verbatim wording from the response

“Induction training materials for healthcare professionals involved in medicines administration will be strengthened to emphasise the management of missed doses of time-critical medicines, including the requirement to escalate to the medical team where a dose is likely to be missed or has been omitted. The Trust Medicines Management Moodle training package is also under review, so will strengthen any sections on missed doses/time critical medicines for all clinical substantive professionals.”

Source location

Response from University Hospitals Birmingham NHS Foundation Trust
Page 5 · response
Published 14 August 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

Undertake spot-check assessments of registered nurses’ discharge-medicines practice and share outcomes and learning through monthly clinical assurance meetings.

Verbatim wording from the response

“Matrons and ward managers at Solihull Hospital are also undertaking spot check assessments of registered nurses’ practices when discharging patients from the medical and surgical wards. Outcomes and learning opportunities will be shared and discussed within the Clinical Assurance monthly group meetings with nurse leaders and managers. There have been no further reports of patients being discharged with incorrect medications, CDs not belonging to patients or medications belonging to another patient since this incident was raised at Solihull. The incidents have demonstrated several patient safety risks associated with the storage, handling and checking of medicines within clinical areas across Solihull Hospital. The safe and secure and handling of medicines (SaSHM) is audited bi-annually by the pharmacy department across the Trust.”

Source location

Response from University Hospitals Birmingham NHS Foundation Trust
Page 7 · response
Published 14 August 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

Monitor compliance with medicines standards through weekly local assessments and monthly hospital, medication-safety, and group governance reporting until practice improvement is demonstrated.

Verbatim wording from the response

“Monitoring of compliance against Trust standards will be undertaken locally through documentation, discharge and bedside assessments and audited weekly until practice improvement, standards and checks described in the Trust Medicines Code take place on every discharge (3.2.6 Medicines Code) and adhered to. Compliance against medicine’s standards is now being reported monthly through the Hospital’s Quality and Safety meetings and Safe Medication Practice Group. Any themes and practice safety risks are reported to both the Group Care Quality and Medicines Management Advisory Group.”

Source location

Response from University Hospitals Birmingham NHS Foundation Trust
Page 7 · response
Published 14 August 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

Circulate a Trust patient-safety notice reinforcing procedures for obtaining and escalating time-critical medicines, using safety huddles, meetings, newsletters, and governance channels.

Verbatim wording from the response

“These medicines omissions have been retrospectively reported on the Trust RADAR incidents system and immediate actions have been taken to address the procedural failings with the individual responsible nurses. The patient safety incident and learning have been shared across surgical and medical inpatient clinical teams. To strengthen awareness, a Trust patient safety notice will be circulated to reinforce the process for obtaining time-critical medicines both in and outside of normal working hours, to reduce the risk of missed administrations across the organisation. The notice will be shared in department Safety Huddles, Ward team meetings, Newsletters, Clinical Assurance and Care Quality meetings.”

Source location

Response from University Hospitals Birmingham NHS Foundation Trust
Page 5 · response
Published 14 August 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

Complete corrective action plans addressing medicines-management audit findings and report progress through the monthly Care Quality agenda.

Verbatim wording from the response

“Compliance against SaSHM standards declined from 98% to 82% in the last quarterly audit cycle at Solihull Hospital which was the largest decline in performance across all the hospital sites. Ward managers, with the support of the respective speciality’s Matron, are responsible for developing and completing action plans based on the results of the audits and report progress against compliance within the monthly Care Quality agenda. Audit outcomes have demonstrated areas of operational non-compliance however there have been no patient safety incidents or harm resulting from the standards not being met. Assurance has been received that actions have been completed with immediate effect.”

Source location

Response from University Hospitals Birmingham NHS Foundation Trust
Page 7 · response
Published 14 August 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

UHB Pharmacy could not have prevented the missed doses because they occurred outside normal hours and Fidaxomicin was available through emergency drug cupboards.

Verbatim wording from the response

“There are no actions UHB Pharmacy could have taken to prevent either of the missed doses as the incidents occurred out of normal working hours, and the drug was available in the emergency drug cupboard and dispensed directly to the ward. The expected standard for any omission of prescribed medication is that the omission is immediately escalated to the nurse in charge of the shift as per policy and procedure (medicine code).”

Source location

Response from University Hospitals Birmingham NHS Foundation Trust
Page 2 · response
Published 14 August 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

Fidaxomicin was available throughout admission; missed doses resulted from nursing failures to record and communicate its location, not pharmacy supply failure.

Verbatim wording from the response

“Fidaxomicin was available either on the ward, in main pharmacy or within the emergency drug cupboard at Solihull Hospital throughout Mr Simpson’s admission and accessed as per the medicines code. On the 16 June 2024, the drug was in the bedside secure locker however nursing handovers had failed to communicate and/or document on PICS noting, where the medication was being securely stored and the RNs were not routinely checking the bedside lockers before administrations. In the event a registered nurse cannot locate a drug dose, then the emergency drug cupboard should be utilised. Fidaxomicin has low usage as it is a restricted antibiotic used as a second line treatment for clostridium difficile or on the recommendation of a microbiologist. Fidaxomicin is a high-cost medication (£1,600 for a box) and is therefore not recommended as a stock drug on any location across UHB clinical areas.”

Source location

Response from University Hospitals Birmingham NHS Foundation Trust
Page 3 · response
Published 14 August 2025

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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

    Ensure the Fit for Discharge checklist is readily accessible in clinical areas, at bed spaces, and near patient medication lockers.

    Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2025.
  2. 2

    Share incident findings and patient-safety learning across surgical, medical, hospital, community, and Trust quality and safety forums.

    Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 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

Ensure the Fit for Discharge checklist is readily accessible in clinical areas, at bed spaces, and near patient medication lockers.

Verbatim wording from the response

“The leaders and managers of each clinical area will be responsible for ensuring that the webinar is accessed by registered nurses as part of their essential training updates. The Matrons are responsible for ensuring that wards have the ‘Fit for Discharge’ checklist readily accessible within clinical areas, including at bed spaces and near patient medication lockers, where the discharge process is undertaken. This is to ensure that practice standards are consistently followed and adhered to.”

Source location

Response from University Hospitals Birmingham NHS Foundation Trust
Page 6 · response
Published 14 August 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 incident findings and patient-safety learning across surgical, medical, hospital, community, and Trust quality and safety forums.

Verbatim wording from the response

“These medicines omissions have been retrospectively reported on the Trust RADAR incidents system and immediate actions have been taken to address the procedural failings with the individual responsible nurses. The patient safety incident and learning have been shared across surgical and medical inpatient clinical teams. To strengthen awareness, a Trust patient safety notice will be circulated to reinforce the process for obtaining time-critical medicines both in and outside of normal working hours, to reduce the risk of missed administrations across the organisation. The notice will be shared in department Safety Huddles, Ward team meetings, Newsletters, Clinical Assurance and Care Quality meetings.”

Source location

Response from University Hospitals Birmingham NHS Foundation Trust
Page 5 · response
Published 14 August 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