Custodial medication interaction warnings
Failure to provide clear warnings to prisoners about the critical risks of combining prescribed medications with other substances.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
77match
Sheila Steggles
Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and junior staff failing to consult on critical medication interactions.
Matched on
terms: interaction, medication
PFD report
73match
Jan Goodliffe
Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, which may have contributed to the deceased's death.
Matched on
terms: interaction, medication
PFD report
69match
Graham Saffery
The BNF, a key GP resource, lacks warnings for co-prescribing amitriptyline and oxycodone, despite other guidance recommending caution and monitoring for this interaction.
Matched on
terms: interaction, warning
PFD report
69match
Susan Gladstone
The report identifies a potential interaction between tramadol and warfarin that caused a dangerously high INR level, and that there was no warning to the prescribing doctor about this possible interaction.
Matched on
terms: interaction, warning
PFD report
65match
Ian Miller
A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading of prescribed medication, posing a significant risk to prisoner safety.
Matched on
terms: medication
PFD report
61match
Carl Smith
Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing related to these checks was deficient.
Matched on
terms: custodial
PFD report
61match
Devinder Seth
Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in orthogeriatric patients, leading to unrecognised opiate toxicity.
Matched on
terms: medication
PFD report
61match
Jonathan Earp
Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected illicit drug use.
Matched on
terms: medication
PFD report
61match
Andrew McCall
A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially harmful prescribing of other medications for drug-seeking behavior.
Matched on
terms: medication
PFD report
61match
Beatrice Dawkins
Critical patient allergy information was not accessible or flagged to clinicians, despite being recorded in medical notes, resulting in the inappropriate prescription of a contraindicated medication.
Matched on
terms: medication
IMB recommendation
61match
North West and Midlands STHF (2023)
For the fifth year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detained individuals with access to their prescribed medication. The Board continues to note that the welfare of detained individuals has been adversely affected by this situation. This occurs particularly in holding...
Matched on
terms: medication
PFD report
57match
Abdeslam Benelghazi
Concurrent prescribing of methadone with multiple sedative medications, particularly clonazepam, created a dangerous combined effect of central nervous system and respiratory depression, significantly increasing the risk of sudden death.
Matched on
terms: medication
PFD report
57match
Samantha Gould
There is a national gap in guidance for sharing mental health patient care plans and risk information with pharmacies, enabling vulnerable 16-17 year olds to access overdose medication.
Matched on
terms: medication
PFD report
57match
Maria McGauran
The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about the patient's excessive use and hoarding of codeine.
Matched on
terms: medication
PFD report
57match
Steven Bowker
The prolonged prescription and use of opiate medication pose significant dangers to patients.
Matched on
terms: medication
PFD report
57match
Kevin McDonnell
Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain accurate documentary evidence following a death in custody.
Matched on
classifier match
PFD report
57match
Thomas Kingston
There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing or switching them when ineffective or causing adverse effects.
Matched on
terms: medication
PFD report
57match
Chloe Burgess
The severe interaction between amitriptyline, paroxetine, and ivabradine is poorly understood, not flagged by prescribing software, and prescribers lack full awareness, posing a significant toxicity risk.
Matched on
terms: interaction
PFD report
57match
Aaron Atkinson
There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for at least 12 months after initiating antipsychotic medication.
Matched on
terms: medication
IOPC learning recommendation
57match
Care and attention for man whilst detained in custody – Thames Valley Police, June 2021
The IOPC recommends that a review of PACE Code C Annex H is undertaken in relation to the guidance on dealing with detainees withdrawing from drugs and alcohol, including withdrawal symptoms masking other serious problems. The review should include consideration of the dangers of dual medication and amendments to PACE Code C Annex H, point 3, adding that...
Matched on
terms: medication
IMB recommendation
56match
North and Midlands STHF (2020)
For the third year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detainees with access to their prescribed medication. The Board continues to note that detainee welfare has been adversely affected by this situation. This occurs particularly in holding rooms and reporting centres....
Matched on
terms: medication
IMB recommendation
56match
North and Midlands Short Term Holding Facilities (2022)
For the fourth year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detained individuals with access to their prescribed medication. The Board continues to note that the welfare of detained individuals has been adversely affected by this situation. This occurs particularly in holding...
Matched on
terms: medication
IMB recommendation
56match
North West and Midlands STHF (2024)
For the sixth year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detained individuals with access to their prescribed medication. The Board continues to note that the welfare of detained individuals has been adversely affected by this situation. This occurs particularly in holding...
Matched on
terms: medication
PFD report
53match
Shalane Blackwood
The prison lacks adequate provision for complex health needs, has insufficient staff for prisoner regimes, faces rife NPS use, and has unclear decision-making tools and staff awareness for physical symptoms alongside mental health issues.
Matched on
classifier match
PFD report
53match
Sean Davies
Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. Furthermore, some operational support staff lacked proper training or adhered to it.
Matched on
classifier match
Article 2 learning point
52match
AC — HMP Brixton - LP F
Drug Dependence Reviews of dual diagnosis patients should consider the range of medication prescribed to a patient.
Matched on
terms: medication
PPO recommendation
52match
The Head of Healthcare, lead GP and lead pharmacist at HMP Wandsworth
The Head of Healthcare, lead GP and lead pharmacist should review the ‘homely remedies’ protocol to ensure that it makes reference to checking a prisoner’s prescribed medication to ensure no contraindications before the provision of a ‘homely remedy’.
Matched on
terms: medication
IMB recommendation
52match
Rye Hill (2023)
The Board is concerned that processes designed to ensure prisoners have sufficient prescribed medication with them when transferring to Rye Hill are not being consistently applied across the prison estate.
Matched on
terms: medication
IMB recommendation
52match
Berwyn (2023)
Prisoners from England are not allowed to access medication which has not been approved by Betsi Cadwaladr (Betsi Cadwaladr University Health Board), the local healthcare provider. Regarding medication for mental health issues in particular, this causes distress.
Matched on
terms: medication
Article 2 learning point
52match
Mr Everest — HMP Altcourse - LP 1
There needs to be much speedier medicines reconciliation, post reception. In prisoners, like Mr Everest, who are prescribed drugs like antidepressants, this needs to be within 24 hours to avoid withdrawal symptoms. There needs to be a robust administration process whereby a summary is acquired from the GP in the community, outlining the person’s medication. If someone is...
Matched on
terms: medication
PFD report
49match
Kirk Duboise
There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were not reviewed during the reception process.
Matched on
classifier match
PFD report
49match
Satheeskumar Mahatheaven
Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.
Matched on
classifier match
PFD report
49match
Terence Adams
Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to follow up on missed appointments contributed to a lack of care.
Matched on
classifier match
PFD report
49match
Jack Portland
No specific concerns regarding future deaths were detailed in the provided text, only contact information.
Matched on
classifier match
PFD report
49match
Marlon Watson
Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern for managing prisoner welfare and suicide risk.
Matched on
classifier match
PFD report
49match
Darren Docherty
Prisoners released without accommodation are unable to access crucial GP and community mental health services, creating significant risks to their health and safety.
Matched on
classifier match
PFD report
49match
Marlin Burrows
The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared with medical staff, and there was no joint prison/healthcare oversight.
Matched on
classifier match
PFD report
49match
Edward Hands
Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, failed recognition of clinical deterioration, and delayed medical assessment.
Matched on
classifier match
IMB recommendation
48match
Heathrow and City airports Short Term Holding Facilities (2021)
The Home Office should ensure that the new system for giving detainees access to their prescription and over-the-counter medication is designed and implemented without further delay.
Matched on
terms: medication
IMB recommendation
48match
Scotland and Northern Ireland Short-Term Holding Facilities (2022)
We would urge the Minister to request that the Home Office carry out an urgent assessment of the risks to detained people as a result of the removal of their prescription medications. These risks should then be taken into account when designing a practical strategy for ensuring that detained people receive their appropriate medication. The desired outcome would...
Matched on
terms: medication
IMB recommendation
48match
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
We reiterate our previous recommendation regarding the provision of prescription medication. We repeat our urge for the Minister to request that the Home Office carry out an urgent assessment of the risks to detained people as a result of the removal of their prescription medications and design a practical strategy for ensuring that detained people receive their medication....
Matched on
terms: medication
IMB recommendation
48match
Cardiff (2024)
The Board again wishes to highlight applications about medication/ prescriptions continue to be received at a very high level and recommends further consideration be given to addressing this.
Matched on
terms: medication
IMB recommendation
48match
London short term holding facilities (STHF) (2025)
Eaton House and London City Airport urgently need a workable solution for administering personal medication. This issue has been raised for many years now, including at Ministerial level.
Matched on
terms: medication
PPO recommendation
48match
The Head of Healthcare
The Head of Healthcare should ensure that when high or medium risk medications such as amitriptyline are prescribed, the prescriber ensures that a further in-possession risk assessment takes place in line with local and national policy.
Matched on
terms: medication
IMB recommendation
48match
Heathrow Short Term Holding Facility (2020)
The Home Office should ensure that the new system is provided as quickly as possible to ensure that people in detention can access their own prescription medication and common non-prescription medication (paras. 9.2 - 9.5; 18.2 – 18.3; 26.2; 34.2).
Matched on
terms: medication
IMB recommendation
48match
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2020)
That the administration of detainees’ personal prescribed medication, in airport HRs be resolved forthwith.
Matched on
terms: medication
IMB recommendation
48match
Bedford (2020)
Request that the Head of Safety (or other nominated officer) be kept informed of any prisoner who has been subject to the protocol for anyone missing more than three doses of medication.
Matched on
terms: medication
IMB recommendation
48match
London Heathrow and City Airports (2022)
[London City Airport and Eaton House] The Board recommends that a workable solution can be found for those detained to have access to their prescribed medication. (See paragraphs 6.4.6 and 8.4.3)
Matched on
terms: medication
IMB recommendation
48match
Dovegate (2023)
It is important there is a medical prescriber in Reception for out of standard hours arrivals, to ensure prisoners get the medication they need on their first night.
Matched on
terms: medication
IMB recommendation
48match
North West and Midlands STHF (2025)
For the seventh year in succession, the Board repeats its concern at the lack of proper procedures that would allow the Home Office or its contractors to routinely provide detained individuals with access to their own medication. The Board considers the welfare of some of those who have been detained may have been adversely affected by this situation,...
Matched on
terms: medication