PFD report

Bridget May CAHILL · Prevention of Future Deaths report

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Issued 11 Jun 2014•Black Country

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
0

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 raised2

  1. Failure to individualise maximum morphine doses to body weight, comorbidities and other relevant factors
    Part of recurring concern: Failure to individualise medication doses to patient-specific factors
  2. Failure to account for morphine buildup during long-term therapy
    Part of recurring concern: Inadequate review of long-term medication use
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    This case does not prompt a review of the maximum permitted morphine dose because analgesic requirements vary and tolerance develops with chronic administration.

    Stated by Medicines and Healthcare products Regulatory AgencyNo action considered necessaryThe respondent said that no further action was needed.

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 individualise maximum morphine doses to body weight, comorbidities and other relevant factors

Wider context from the report

“The evidence I heard was that Mrs. Cahill was admitted to Walsall Manor Hospital on 10th September 2013. She had a one day history of unresponsiveness, had a background of Parkinson’s disease, dementia and chronic backache. She lived in a residential home. On admission she had pinpoint pupils suggesting morphine overdose which was partially reversed with an antidote. Blood tests showed high calcium levels suggestive of dehydration, or possibly a tumour and there was a suggestion of possible ongoing infection. She had treatment with IV fluids, IV antibiotics and Naloxone, but she deteriorated and died. She was on morphine night and morning and also oral morphine during the day if and when required. The maximum dose of Oramorph was 20 millilitres per day, 5 millilitres at a time, dosages to be 4 to 6 hours apart. The evidence I heard was that at no time prior to her death did she have the maximum permitted dose. My concern relates to how it is that a person who is prescribed morphine and who has less than the amount prescribed for them, can nevertheless suffer an overdose. I write to enquire whether attention needs to be given to the maximum dose that can be recommended and whether it is, or should be, subject to factors such as body weight, any co morbidities and any other factors and whether attention should be directed towards the possible buildup of morphine in the body for those involved in long-term therapy. ”

Is this part of a recurring concern?

Yes — Failure to individualise medication doses to patient-specific factors.

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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 account for morphine buildup during long-term therapy

Wider context from the report

“The evidence I heard was that Mrs. Cahill was admitted to Walsall Manor Hospital on 10th September 2013. She had a one day history of unresponsiveness, had a background of Parkinson’s disease, dementia and chronic backache. She lived in a residential home. On admission she had pinpoint pupils suggesting morphine overdose which was partially reversed with an antidote. Blood tests showed high calcium levels suggestive of dehydration, or possibly a tumour and there was a suggestion of possible ongoing infection. She had treatment with IV fluids, IV antibiotics and Naloxone, but she deteriorated and died. She was on morphine night and morning and also oral morphine during the day if and when required. The maximum dose of Oramorph was 20 millilitres per day, 5 millilitres at a time, dosages to be 4 to 6 hours apart. The evidence I heard was that at no time prior to her death did she have the maximum permitted dose. My concern relates to how it is that a person who is prescribed morphine and who has less than the amount prescribed for them, can nevertheless suffer an overdose. I write to enquire whether attention needs to be given to the maximum dose that can be recommended and whether it is, or should be, subject to factors such as body weight, any co morbidities and any other factors and whether attention should be directed towards the possible buildup of morphine in the body for those involved in long-term therapy. ”

Is this part of a recurring concern?

Yes — Inadequate review of long-term medication use.

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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

This case does not prompt a review of the maximum permitted morphine dose because analgesic requirements vary and tolerance develops with chronic administration.

Verbatim wording from the response

“This case does not prompt a review of the maximum permitted dose given the interindividual range of dose needed to achieve analgesia and the tolerance that is expected to develop as a result of chronic morphine administration.”

Source location

2015-0266-Response-by-MHRA
Page 2 · response
Published 11 June 2014

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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

Maximum morphine dosing need not be adjusted for body weight or comorbidities because prescribing information already advises dose reduction in specified circumstances.

Verbatim wording from the response

“2. Should the maximum dose be subject to factors such as body weight and any co-morbidities?”

Source location

2015-0266-Response-by-MHRA
Page 2 · response
Published 11 June 2014

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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

The evidence does not support excessive accumulation of morphine metabolites in this case, as would be expected from impaired renal elimination.

Verbatim wording from the response

“3. Should attention be directed towards the possible build-up of morphine in the body for those involved in long-term therapy?”

Source location

2015-0266-Response-by-MHRA
Page 2 · response
Published 11 June 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