1,410 reports
Information drawn from published reports and official responses.
Alison Mary Ross died on 11 November 2022 from an intraabdominal haemorrhage following an ascitic drain procedure performed on 10 November 2022. The report raises concern that there was no guidance for monitoring medicines self-administered by patients who did not take them when dispensed, relevant to the administration of apixaban before the procedure.
University Hospitals Sussex NHS Foundation Trust
David Joseph Crompton, who had epilepsy, was left without his prescribed Tegretol for approximately 10 days in April 2024 and again in December 2024. His falls in both periods occurred when he was without the medication, and the inquest recorded a fall downstairs on 13 December 2024, with causes of death including hypoxic ischaemic encephalopathy, out-of-hospital cardiac arrest and cervical spine injury. The principal concerns were delays in supplying essential anti-epileptic medication, reliance on family members to seek alternative supplies, and the absence of clear systems for managing medication shortages.
General Pharmaceutical CouncilMidway Pharmacy
Darren James CARRINGTON died after collapsing with a fatal level of Zopiclone in his blood and did not recover. The inquest concluded that the death was misadventure, being an impulsive overdose while under the influence of alcohol. Concerns included the prescribing of potentially dependency-forming medication, excessive Zopiclone prescribing over 57 days, and the ability of receptionists and clinicians to override computer warnings and other safeguards.
NHS Brighton and Hove Clinical Commissioning GroupNHS Surrey and Sussex Integrated Care BoardNorth Laine Medical Centre
Christopher Collinson was admitted to Birmingham Heartlands Hospital with suspected deep vein thrombosis and pulmonary embolism, but was not seen by a doctor for several hours. He was prescribed a prophylactic rather than therapeutic dose of Enoxaparin, later suffered a cardiac arrest, and died on 15 June 2021. Concerns related to the patient-allocation system not making it clear when an allocated patient had not been seen, and the electronic prescribing system not requiring a secondary medication check.
University Hospitals Birmingham NHS Foundation Trust
Imogen Heap, aged 17, died after ingesting a very large quantity of propranolol, with smaller amounts of fluoxetine and paracetamol, and subsequently suffering propranolol toxicity, bradycardia and cardiac arrest. The principal concern was that propranolol remains widely prescribed, including to young people with anxiety, while the risks of overdose may be under-appreciated.
National Institute for Health and Care Excellence
Thomas Joseph Geraghty entered the sea from a beach at Eastbourne on 28 June 2023 and was later recovered from the water; resuscitation was unsuccessful and his death was confirmed. The inquest concluded suicide. The report raises concern that patients may be deregistered from GP surgeries without adequate review or communication to ensure continued access to vital medication, particularly where no new GP details are provided.
Chelsfield Surgery
Sufia Begum was admitted to Queen Elizabeth Hospital with vomiting, confusion and generalised weakness after being prescribed clarithromycin while taking verapamil. She died on 24 April 2018 from multiorgan failure and calcium channel blocker toxicity, with the inquest concluding that she died from an unrecognised adverse drug interaction. The principal concern was that not all doctors were aware of the BNF mobile device app, identified as a useful tool for detecting potential drug interactions.
NHS Birmingham and Solihull Integrated Care BoardNHS England
Michael Dent-Jones was found deceased at St Catherine’s Priory on 14 July 2018 after an unintentional Tramadol overdose. The report identifies concerns that Approved Premises staff may not have been familiar with or applying guidance on the delivery and collection of residents’ prescribed medication and other resident-safety procedures.
HM Prison and Probation ServiceHM Prison Service
Jacqueline GREEN was admitted to Bedford Hospital after a fall and was found to be very weak, frail, cachectic and dehydrated. She received paracetamol at a dose intended for patients weighing over 50 kg despite weighing 33.6 kg, subsequently developed paracetamol-induced liver injury and died from liver failure. The concerns included inadequate safeguards for prescribing paracetamol to low-weight adults, unexplained variation in the administration of doses, and incomplete implementation of relevant safety measures.
Bedfordshire Hospitals NHS Foundation Trust
Carol Buchanan was admitted to hospital after a fall and later deteriorated following the combined prescription of Itraconazole and Simvastatin, which led to rhabdomyolysis and muscle necrosis. She died on 26 May 2017 despite treatment. Concerns included inadequate prescription record checking and documentation, failure to recognise the serious drug interaction, missed opportunities to act on relevant history, and delays in monitoring and diagnosis.
Royal Bolton Hospital
Donald Vernon Compton, aged 87, was admitted to hospital after developing Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis and Covid-19, and died on 14 February 2021. The principal concerns were prescribing and dispensing errors involving Co-trimoxazole despite a known trimethoprim allergy, including failures by hospital staff and a GP to identify the risk. A separate medication error involving excessive amiodarone dosing was also identified.
Cwm Taf Morgannwg University Local Health Board
Bruce Lee Houghton died at home on 16 April 2020 from combined drug toxicity, with excess paracetamol likely causing liver damage and accumulation of his other medications. The report states that he had not had his annual medication review, and that these reviews did not ask patients about over-the-counter medicines they purchased in addition to prescribed medication.
Department of Health and Social CareNHS Greater Manchester Integrated Care BoardThe Uplands Medical Practice
Megan Nicole JONES, aged 28, was found dead at home after a history of mental health issues and treatment with combined antipsychotic medications. The report states that she was believed to have suffered a fatal cardiac arrhythmia associated with a higher-than-optimal recommended dose of the medications. The principal concern was the absence of a formal policy for regular monitoring, including QTc recording, of patients prescribed Clozapine, particularly when antipsychotic prescribing exceeded 100% of the BNF limit.
NHS Hampshire and Isle of Wight Integrated Care Board
Derrick George Rivers, who had been admitted to full-time care after becoming frail and falling, was mistakenly given a 150mg dose of Clozapine intended for another resident. He was admitted to hospital with altered consciousness and confusion, initially improved, then deteriorated and died on 11 July 2013; the inquest found that he died from natural causes to which the Clozapine may have contributed. Concerns included inadequate medication policies and administration protocols, insufficient auditing and inspection, and incomplete implementation of recommendations intended to reduce the risk of medication errors.
Care Quality CommissionPassmonds House Care HomeRochdale Borough Council
Lewis Robert Begley was admitted to a mental health ward on 12 December 2020 and was found unresponsive in his room on the morning of 15 December 2020 after accessing the medicine room. He was pronounced dead at the scene, and post-mortem examination found a split plastic bag containing tablets in his rectum. Concerns included inadequate recording of medicines held, limited knowledge of what medication may have been taken after patient access, and a lack of fixed training for doctors regarding suspected overdoses.
Norfolk and Suffolk NHS Foundation Trust
Katie Anne WILLIAMS took an intentional overdose of prescribed medication and was admitted to intensive care with severe complications, including aspiration pneumonia and paralytic ileus. She died at Derriford Hospital on 24 May 2021 after developing fatal serotonin toxicity associated with delayed absorption of the overdose and the subsequent administration of a sedative drug. The principal concern was that similar risks may not be fully appreciated by other NHS organisations in comparable cases.
Faculty of Intensive Care Medicine
Aoife Rose McAdam died in Leeds General Infirmary on 4 September 2021 after taking a significant overdose of propranolol. She had sought help shortly after taking the overdose, but two opportunities to send an ambulance sooner were missed. The report’s concerns included her being left with a significant quantity of propranolol after she said she no longer wanted or needed it, and delays in providing help after the overdose.
Burton Croft Surgery
Samuel David Morgan died at home on 16 January 2020 as a consequence of self-suspension. His risk of taking his own life had not been identified, and a review assessment was not set when citalopram was prescribed. Concerns included a change in mood after starting the medication and whether clearer warnings about the risk of suicidal thinking in young adults would better capture patients’ attention.
Department of Health and Social CareMedicines and Healthcare products Regulatory Agency
Neil Michael Yates, aged 53, died in a drug-related death; the inquest recorded mixed drug toxicity and bronchopneumonia, with chronic obstructive pulmonary disease and cirrhosis also noted. The substantive concern was delays in information about prescriptions from voluntary and NHS organisations reaching GP surgeries, creating a risk that further medication could be prescribed without knowledge of existing prescriptions.
NHS EnglandOffice of the Chief Coroner
Amanda Jane Kramer, aged 56, was found unresponsive at home on 31 December 2022 and died from an overdose of prescribed zopiclone. The report raised concerns that zopiclone had been prescribed for approximately 18 years without clear evidence that its ongoing need, associated risks, or adherence to dosage instructions had been reviewed, including after previous deliberate overdoses of prescribed medication.
Department of Health and Social CareNorth East London NHS Foundation TrustWood StreetWood Street Health Centre
