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Best matches
Report results use published report text and related indexed information, ranked for relevance.
Data updated 7 September 2026
Concerns
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Unsafe medication administration
115 reports 146 recipients
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Failure to identify clinically significant medication risks
54 reports 83 recipients
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Failure to secure and control medication
30 reports 55 recipients
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Unreliable medication dosage verification and communication
16 reports 23 recipients
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Incomplete medication safety guidance for prescribers
14 reports 29 recipients
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Unreliable medication management in care homes
11 reports 16 recipients
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Failure to ensure patients receive the correct prescribed medication at hospital discharge
13 reports 16 recipients
Reports
Matched using report evidence
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Peter COLE · Prevention of Future Deaths report
Related indexed information (1) That repeat medication is not being adequately monitored, leading to many (often older and/or mentally infirm) patients building-up dangerous quantities of prescribed medication. (2) That the inadequate supervision of prescribed (repeat) medication is so widespread that the co... On 19/09/2019 I commenced an investigation into the death of.
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Juanita Boate Nti · Prevention of Future Deaths report
Related indexed information Failure of GP and pharmacist to communicate when prescription instructions are unclear or conflicting Failure to clearly record prescribed medication strength and administration volume Failure to identify conflicting medication concentration and specify administration volume before dispensing Failure t... Discuss liquid morphine safety with London.
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Mark Alan Smith · Prevention of Future Deaths report
Related indexed information It was conceded, accordingly, that there was - and remained - no policy or procedure in place to mitigate the clear risk involved in GPs prescribing unnecessarily excessive quantities of (potentially dangerous) prescription medication (at inappropriate frequency) to a clearly vulnerable cohort of patients, and therefore no policy or procedure is.
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Margaret Joy Daly · Prevention of Future Deaths report
Related indexed information On the 14th of June 2024 I commenced an investigation into the death of Margaret Joy Daly (DOB 23.10.32 DOD 10.6.24). Establish a prescribing safety process requiring access to patient notes, communication of falls risk, and escalation or assessment when safe prescribing is uncertain. Maintain a dedicated multidisciplinary... Roll out the.
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Judith Lesley Marshall · Prevention of Future Deaths report
Related indexed information (1) The Pharmacy’s Errors Book shows a number of drug errors (including higher or lower dose tablets and three wrong drugs) over a number of years. Establish a National Medication Safety Network and identify medication safety officers in large healthcare provider organisations, including community pharmacy companies. ...ghlight prescribing-error.
Recipients
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Medicines and Healthcare products Regulatory Agency
Medicines and medical devices regulator
79 reports Latest 1 Apr 2026
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UK Fatal Anaphylaxis Registry
1 report Latest 6 Apr 2023
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National Confidential Inquiry into Suicide and Safety in Mental Health
University research centre
1 report Latest 18 Mar 2022
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