1,410 reports
Information drawn from published reports and official responses.
Peter Cole was an older person with dementia who overdosed on Tramadol, which had been supplied on repeat prescription. The report raised concerns that repeat medication was not being adequately monitored, leading some older or mentally impaired patients to accumulate dangerous quantities of unused prescribed drugs and contributing to waste of healthcare resources.
NHS England
Juanita Boate Nti had complex congenital diseases and was receiving palliative care at home. She received twenty times the intended morphine dose after the prescription and symptom control plan failed to clearly specify the volume, and the prescription contained two different concentrations. She suffered respiratory arrest and died following an accidental morphine overdose, with concerns also identified about the EMIS prescribing system not offering the relevant morphine strength.
NHS England
Mark Alan Smith was found deceased at home on 5 March 2024 after ingesting large quantities of prescription medication, including Mirtazapine and Pregabalin, together with a significant quantity of alcohol. The report identified a lack of GP policies or procedures for reviewing medication quantities prescribed to vulnerable patients with histories of addiction, self-harm, suicidal ideation or prescription medication overdose, and stated that this failure probably contributed more than minimally to the death.
Addison House Surgery
Margaret Joy Daly was an in-patient at Wrexham Maelor Hospital and, despite being assessed as at significant risk of falling, received lorazepam after a doctor prescribed it without reviewing her full records. She later had an unwitnessed fall and sustained the injury that resulted in her death; the principal concern was that sedative prescribing could occur without consideration of the patient’s full medical records and risk assessments.
Betsi Cadwaladr University LHB
Judith Lesley Marshall was prescribed morphine sulphate 10mg twice daily, but a pharmacy dispensed 60mg capsules. She took the capsules as prescribed and was found dead on 30 September 2009; the inquest recorded bronchopneumonia and the effects of morphine, with a conclusion of accidental death. The principal concerns were pharmacy dispensing errors, the adequacy of checking and monitoring systems, and the absence of central monitoring of prescription errors.
Department of Health and Social CareGeneral Pharmaceutical CouncilNHS EnglandRoyal Pharmaceutical Society of Great Britain
Mr John Michael James was admitted to hospital with malnutrition and a bowel obstruction caused by an adenocarcinoma, and later underwent surgery and intensive care. He died from a pulmonary embolism after three missed doses of prescribed anticoagulation medication; the report raised concern that the refusals were not escalated and that there was no electronic alert to notify medical staff when doses were not administered.
Barts Health NHS Trust
Debra Bates was found dead at home on 15 June 2023. Post-mortem toxicology found prescribed medication at above therapeutic levels, and the evidence indicated that a mixture of medication had an enhanced sedative and respiratory depressant effect. A prior recommendation to change her prescriptions from weekly supplies to a three-day and four-day cycle was not implemented; concerns included the continuation of weekly prescribing and insufficient investigation of how to implement the proposed approach safely.
Park Surgery
Charlie Marriage, who had epilepsy controlled with Fycompa, was unable to obtain his repeat medication after being told to self-isolate for Covid and encountering difficulties with his GP practice, pharmacy and 111. He suffered a fatal seizure at home after going without medication. The report identified concerns about whether patients with medication-dependent, “cliff-edge conditions” are recognised, prioritised and given appropriate safety-netting and access to emergency supplies.
NHS England
Andrew John Hooper died after taking methadone prescribed to his girlfriend, with the stated cause of death being respiratory failure, hypoxic brain injury and methadone toxicity. The concerns were that the medication was not secured, was available in a quantity sufficient for a fatal dose, and that the person prescribed it appeared unaware of the risks to others and unable to keep it safe.
Clinical Commissioning Group (Devon)Local Drug and Alcohol Team (Devon)NHS Devon Integrated Care Board
Maria Susan McGAURAN had been prescribed codeine and citalopram and died at home on 28 November 2018 due to the combined toxicity of those medications. Concerns were raised that she had hoarded and taken medication erratically, but the Surgery did not undertake a requested medication review or consider alternative pain management earlier.
Alvaston Medical Centre
Mohammed Ashraful Islam CHOUDHURY, aged 26, died at hospital on 11 January 2023 after being attacked and stabbed by another resident at his supported accommodation. The concerns included inadequate management of the other resident’s known risks, lack of a multidisciplinary plan after he stopped taking medication, and withdrawal of medication support without checking with his GP that prescriptions were being obtained.
East London NHS Foundation Trust
Annette Charlton, who had emphysema and lung fibrosis requiring continuous oxygen therapy, was dispensed Naproxen instead of prescribed antibiotics and died on 28 September 2014. The principal concern was that medication manufacturers used almost identical packaging, which was considered likely to contribute to dispensing errors and potentially patient deaths.
Crescent Pharma LimitedDepartment of Health and Social CareGeneral Pharmaceutical CouncilMedicines and Healthcare products Regulatory AgencyNHS EnglandRoyal Pharmaceutical Society
Victor James Hall died at Salford Royal Hospital on 29 June 2018 after being admitted with shortness of breath and an exacerbation of chronic obstructive pulmonary disease. He was mistakenly administered Phosphate Polyfusor instead of prescribed sodium bicarbonate after dispensing, pharmacy checking and ward checking errors, although the post-mortem and toxicology evidence concluded that the medication error played no role in his death. Concerns were raised about the similar Polyfusor product design and about medication-checking, recording, dispensing, training and supervision procedures.
Medicines and Healthcare products Regulatory AgencyNorthern Care Alliance NHS Foundation TrustNursing and Midwifery Council
Ian Hall, who had Alzheimer’s disease and was vulnerable, was admitted to hospital after a fall. A medicines reconciliation identified that amitriptyline had been dispensed instead of his prescribed atenolol; he subsequently choked on medication, developed aspiration pneumonia, tested positive for Covid-19, and died from aspiration pneumonia and Covid-19 pneumonitis. Concerns included the unclear cause of the dispensing error and the checks in place to prevent inadvertent dispensing to vulnerable adults whose carers administered the medication.
Medicines and Healthcare products Regulatory AgencyNHS Greater Manchester Integrated Care Board
Claire Medhurst was admitted after a polypharmacy overdose, was discharged after treatment, and was readmitted with abdominal pain and severe liver abnormalities. Her acute liver failure was not recognised or treated for about six hours before she deteriorated and died on 24 February 2017. Concerns included the lack of cautionary advice about further use of paracetamol or ibuprofen at discharge and the failure of the laboratory to alert clinicians to abnormal results and toxic paracetamol levels.
Medway NHS Foundation Trust
Sewa Kaur Chaddha was found collapsed at home after taking her husband’s medication instead of her own for several days, including diabetes medication. She died in hospital from hyponatraemia caused by treatment for hypoglycaemia resulting from the accidental ingestion of hypoglycaemic medication. Concerns included the identical appearance of the couple’s dosset boxes, small patient-name labels, and the absence or poor dissemination of guidance for pharmacists supplying medication to people with cognitive impairment.
Community Pharmacy EnglandCommunity Pharmacy Thames ValleyGeneral Pharmaceutical CouncilMedicines and Healthcare products Regulatory AgencyNational Pharmacy AssociationNHS Frimley Integrated Care BoardNHS Specialist Pharmacy ServiceSlough Pharmacy
George Benjamin Rimmer was found deceased at home on 25 October 2018 after being prescribed Oramorph for pain following decompression surgery. The concerns included taking the medicine directly from the bottle rather than measuring doses, possible lack of counselling about exceeding the prescribed dose, and insufficient warnings about excess or cumulative dosing.
Boehringer Ingelheim Limited
Margaret Mary Feeney was found deceased at home after taking excess prescribed medication, with pneumonia also contributing to her death. The principal concern was that prescribing and pharmacy arrangements around longer bank holiday periods allowed excess medication to be supplied to a patient recognised as being at risk of overdose.
Daynight Pharmacy (Macklin Street)Department of Health and Social CareMacklin Street SurgeryNHS Derby and Derbyshire Integrated Care Board
Paul Robert Joseph NASH, who had epilepsy secondary to HSV encephalitis, was found deceased at home on 23 October 2025 after apparently suffering a seizure during the night. He had run out of Carbamazepine and missed three doses. The concerns included that the GP surgery did not appear to be told that he had completely run out of medication and did not prioritise the prescription for same-day collection, as well as wider difficulties for epilepsy patients in obtaining sufficient medication supplies.
Department of Health and Social CareSundon Medical Centre
Saif Mubeen Hussain died at John Radcliffe Hospital on 10 June 2021 after being admitted following an incident in Bracknell, Berkshire, on 3 June 2021; the recorded cause of death was polytrauma. During his transfer between units, he was administered a Heparin infusion at almost eight times the prescribed rate. The report identified concerns about unfamiliarity with anticoagulants, inadequate double-checking, the Guardrails system being switched off, differences between prescription and administration rates not being flagged, and the use of separate hospital computer systems.
John Radcliffe HospitalOxford University Hospitals NHS Foundation Trust
