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
69match
Jan Goodliffe
The coroner raised concerns that non-medically qualified social workers conducted home assessments, missing opportunities to obtain expert medical advice on medication interactions for the deceased.
Matched on
terms: interaction, medication
PFD report
69match
Sheila Steggles
The coroner identified gaps in VTE risk assessment for patients with reduced mobility, insufficient detail in clinical notes and care plans, and a need for improved junior staff consultation on medication interactions.
Matched on
terms: interaction, medication
PFD report
65match
Jonathan Earp
The coroner noted no clear evidence that all unspent Fentanyl patches were returned or discarded appropriately. Staff also did not fully consider the potential impact of a patient taking additional prescribed medication alongside illicit drugs.
Matched on
terms: medication
PFD report
65match
Ian Miller
Concerns were raised about medication management at HMP Usk, where prisoners self-manage drugs that are not securely stored. This contributes to widespread trading of prescribed medication among prisoners, risking future deaths.
Matched on
terms: medication
PFD report
65match
Beatrice Dawkins
The coroner identified that critical information regarding the deceased's chloramphenicol sensitivity, documented since 1997, was not accessible or flagged to clinicians during a later hospital admission, resulting in the medication being prescribed.
Matched on
terms: medication
PFD report
61match
Carl Smith
The quality of custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing regarding these checks appeared deficient.
Matched on
terms: custodial
PFD report
61match
Devinder Seth
Ward staff did not recognise the side effects of opiate medication on an orthogeriatric patient, and there was no clear, easily accessible guidance available to staff on the risks and side effects of opiate medications for this patient group.
Matched on
terms: medication
PFD report
61match
Chloe Burgess
The coroner notes that the dangers of combining amitriptyline, paroxetine, and ivabradine are not widely appreciated and do not trigger prescribing software alerts, and prescribers may lack full understanding of these interactions.
Matched on
terms: interaction
PFD report
61match
Aaron Atkinson
Concerns were raised about the lack of annual ECGs during GP reviews for individuals prescribed long-term anti-psychotic medication. This appears to stem from a lack of clarity and consistency in national and local guidance regarding the recognised cardiac risks.
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
Andrew McCall
The coroner noted that a system dependent on patient self-declaration meant GPs were often unaware their patients were on opiate replacement therapy, risking the prescription of unsuitable medications.
Matched on
terms: medication
PFD report
57match
Samantha Gould
The coroner raises concerns about the lack of national guidance for pharmacies to be involved in medication safety plans for mental health patients aged 16-17, noting this poses a risk of future fatalities.
Matched on
terms: medication
PFD report
57match
Maria McGauran
A requested review of the patient's multiple medications was not undertaken, and the Surgery could have considered alternative pain management earlier to prevent overdose risks.
Matched on
terms: medication
PFD report
57match
Susan Gladstone
The coroner noted a lack of information for prescribing doctors regarding the known interaction between tramadol and warfarin, as this interaction is not listed in the British National Formulary.
Matched on
terms: interaction
PFD report
57match
Steven Bowker
The coroner raises concerns about the potential dangers to patients associated with the prolonged prescription and use of opiate medication.
Matched on
terms: medication
PFD report
57match
Thomas Kingston
The coroner raises concerns about the adequacy of communicating suicide risks associated with SSRI medications. Additionally, concerns are noted regarding the appropriateness of guidance for persisting with or switching SSRIs when no benefit or adverse side effects are experienced.
Matched on
terms: medication
PFD report
57match
Edward Hands
The coroner noted conflicting policies between the prison healthcare provider and prison staff regarding prisoners suspected of being under the influence of illicit substances. This resulted in confusion, a lack of awareness, and a prisoner's clinical deterioration not being recognised or escalated due to missed observations.
Matched on
classifier match
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 coroner identified a lack of provision for prisoners with complex health needs and insufficient staff for segregation unit regimes. Additionally, concerns were raised about an unclear documentary tool for assessing fitness for segregation and healthcare staff's awareness of physical symptoms masked by mental health issues.
Matched on
classifier match
PFD report
53match
Marlin Burrows
The coroner identified that a welfare sheet for monitoring prisoner health lacked clear purpose and completion guidance. Entries by prison staff were not consistently made known to medical staff, and its operation had not been jointly considered by prison and healthcare.
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
The coroner noted a delay in summoning an ambulance and that relevant forms were not seen by staff assessing the risk of self-harm for a new prisoner.
Matched on
classifier match
PFD report
49match
Stephen Farrar
The coroner noted the absence of a formal self-harm or suicide risk assessment for Mr. Farrar upon his admission to Woodhill Prison, despite clear risk factors, and the general lack of such assessment tools in prisons.
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
Paul Hardy
Healthcare staff did not follow instructions to obtain blood and urine samples for a possible cancer investigation, nor did they act on recommendations for INR monitoring samples. There was also a failure to conduct a Significant Event Analysis regarding the death, as recommended by the Clinical Reviewer.
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
Charles Rendell
The coroner raised concerns that the potential side effect of Ciprofloxacin, which can cause depression or psychosis leading to suicidal ideation, is not clearly communicated to patients or sufficiently emphasized to prescribing clinicians.
Matched on
classifier match
PFD report
49match
Joy Ebanks
The coroner noted prolonged prescribing of two dependency-forming drugs without a clear plan for dose reduction, despite the practice's own guidance highlighting the hazards of long-term opioid and gabapentinoid use for chronic pain.
Matched on
classifier match
PFD report
49match
Stephen Coster
The coroner identified inadequate record keeping, healthcare staff failures in observation and assessment, and a lack of care plans and communication protocols between healthcare and prison staff. There was insufficient understanding among prison staff of emergency procedures, leading to delays in hospital transfer.
Matched on
classifier match
PFD report
49match
Kevin McDonnell
Prison staff misunderstood the need for meaningful ACCT observations, treating them as superficial checks, and did not share risk-pertinent information. The coroner also noted failures in securing and retaining accurate documentary evidence after the death.
Matched on
classifier match
PFD report
49match
Sean Davies
The coroner raised concerns about the incomplete implementation of risk formulations for prisoners with IPP sentences. Welfare checks by prison officers did not adhere to national guidance, and some operational support group officers lacked or did not follow essential training.
Matched on
classifier match
Scottish FAI
49match
Richard Hugh McGhie
However I wish to make it clear to Sedexo that such record keeping is not acceptable and in the case of another prisoner suffering from epilepsy might have disastrous consequences for that prisoners care. One hopes that appropriate corrective measures will be taken to ensure all such logs are fit for purpose in the future and it may...
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