High-risk medication monitoring
Inadequate or absent arrangements for monitoring patients prescribed high-risk medicines, leading to potential harm.
Source spread
Where this theme appears
This theme appears across 16 independent accountability sources, so the source mix matters as much as the headline total.
2 inquiry recs
53 PFD reports
2 committee recs
30 HSSIB recs
30 CQC actions
9 PPO recs
6 patient safety alerts
2 Scottish FAIs
1 Article 2 learning point
31 DHR recs
16 PHSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(2)
IBI-7a(ii) — Tranexamic Acid - Scotland, Wales and NI
Recommendation: In Scotland, Wales and Northern Ireland offering the use of tranexamic acid should be considered a treatment of preference in respect of all eligible surgery.
Gov response: The Scottish Government’s Oversight and Assurance Group (OAG) Chair and Deputy Chair wrote to Health Boards in November 2024 asking them to review practice within their Board and confirm that they are offering tranexamic acid …
Accepted in part
IBI-7a(i) — Transfusion Committees and Tranexamic Acid - England
Recommendation: In England, Hospital Transfusion Committees and transfusion practitioners take steps to ensure that consideration of tranexamic acid be on every hospital surgical checklist; that hospital medical directors be required to report to their boards and the chief executive of their …
Gov response: UK’s governments Recommendation 7 includes an especially complex set of sub recommendations. To ensure a joined up approach across the four nations, experts from across the four nations NHS bodies, blood services and external bodies …
Accepted in part
Prevention of Future Deaths reports(53)— showing 50 strongest matches
Labhuden Amarshi Vaghadia
Concerns: The coroner raised concerns about a community nurse administering anticoagulant medication without seeking medical advice despite previous bleeding, and failing to share this information with other professionals. The report also identified a lack of the nurse's professional insight and training.
Response (Leicestershire Partnership NHS): • The Trust conducted a review of Mrs Vaghadia's death and considered current community nurse practices for medication administration. • The Trust stated it would re-inform all healthcare professionals about … (AI summary)
Responded
Lucy Kilvert
Concerns: The coroner noted a delay in performing a CT scan of the head for Mrs. Kilvert and raised concerns that NICE Guidelines may insufficiently emphasise the significance of blood-thinning medication in elderly patients who have fallen when considering a CT scan.
Overdue
James Edward Mansfield
Concerns: The GP surgery experienced delays in receiving and reviewing hospital discharge letters, lacking a method to differentiate between serious and non-serious injuries for prompt attention. Strong painkillers were prescribed over the phone without a face-to-face review, despite the patient's complex medical history and multiple rib fractures.
Overdue
Linda Hudson
Concerns: Concerns were raised regarding the hospital's discharge process, specifically that the deceased was discharged with limited medication requiring daily collection due to self-harm risk, her family was not contacted, and the first follow-up nurse visit was scheduled too long after discharge.
Overdue
Stephen Ellis
Concerns: The coroner suggested it would be good practice to supply warfarin home management kits to high-risk patients who have undergone heart surgery and are subsequently on warfarin.
Overdue
Bridget Cahill
Concerns: The coroner raised concerns about a patient experiencing a morphine overdose despite receiving less than the maximum prescribed dose. Attention was drawn to whether recommended maximum doses should consider factors like body weight, co-morbidities, and potential drug buildup in the body for long-term therapy.
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) stated that the case did not prompt a review of the maximum permitted morphine dose. • The MHRA noted that prescribing … (AI summary)
Responded
Christopher Davies
Concerns: The coroner noted insufficient information shared with the patient and family about clozapine interactions with caffeine or smoking cessation, and the warning signs of toxicity. Regular reminders were suggested due to memory issues.
Overdue
Moses McDonald
Concerns: The coroner noted a lack of mandatory and regular glucose testing for patients on antipsychotic medication by the Clozapine clinic.
Response (South London Maudsley NHS Trust): • The physical healthcare policy has been updated to outline staff responsibility for addressing patients' physical health needs, including reference to Maudsley Prescribing Guidelines for Clozapine. • The Trust pharmacy … (AI summary)
Overdue
Judith Saville
Concerns: The coroner identified that medication prescribing did not sufficiently account for a patient's overdose history, and a computer warning system for practitioners was absent. Concerns were also raised about the lack of implementation and auditing of an action plan from a Root Cause Analysis.
Response (Axminster Medical Practice): • The practice confirmed its computer system includes a label advising against repeat or regular Zopiclone use for short courses. • The practice stated that GPs routinely review the summary … (AI summary)
Response (Devon Partnership NHS Trust): • The Trust shared the coroner's findings with the service involved and across the wider trust. • Actions identified in the Root Cause Analysis report have been completed. • The … (AI summary)
Responded
Laurence Boyens
Concerns: Coroner noted insufficient compliance with drug dependence guidelines, specifically regarding blood pressure monitoring before Methadone/Buprenorphine administration and escalation of low readings. Gaps in record-keeping and recognition of patient drowsiness were also identified.
Response: • The organisation commenced a review of its decision to close a case regarding Dr Amayo's care. • The organisation obtained the doctor's comments as part of this review. • … (AI summary)
Response: • The Nursing and Midwifery Council (NMC) stated it would conduct an initial assessment of the referral. • The NMC indicated it would determine how to proceed following the assessment. … (AI summary)
Overdue
Hana Elhamid
Concerns: The coroner noted the patient developed diabetes while on Clozapine, and routine blood tests for blood sugar would likely have prevented the diabetic coma and subsequent trachea injury that led to death.
Response (Department of Health): • Barnet, Enfield and Haringey Mental Health Trust (BEHMHT) conducted a root cause analysis investigation following the death. • The coroner's report was shared with NHS England, which is currently … (AI summary)
Responded
William Bows
Concerns: There were no protocols or guidance for primary care providers on monitoring patients prescribed Amiodarone for liver, thyroid, and respiratory functions. The coroner also noted insufficient monitoring by prescribers during the initial 12 months when toxicity commonly develops.
Response (Sheffield Teaching Hospitals NHS Trust): • The Trust stated that a Shared Care Protocol for Amiodarone was in place at the time of the prescription, outlining responsibilities for monitoring. • The Trust confirmed that the … (AI summary)
Responded
Thomas Thurling
Concerns: The coroner identified inadequate monitoring of a change in medication, a lack of review or alternative care coordinator during an extended absence, and staffing shortages within the Trust.
Response (Norfolk and Suffolk NHS Trust): • The Trust stated it would share the issue of medication monitoring with leads in Pharmacy and Triangle of Care, and with clinical teams to cascade learning. • The Trust … (AI summary)
Responded
Dorothy Delaney
Concerns: The coroner noted Alexander House Health Centre's practice of prescribing concurrent antiplatelet and anticoagulant medications without seeking individual specialist advice, instead relying on general advice for other patients.
Overdue
Hireiti Kuflesion
Concerns: The coroner noted pregnant patients with mechanical heart valves sometimes receive insufficient Clexane doses and inadequate anti-factor Xa monitoring. There was also a lack of understanding among clinicians across the region regarding the increased thrombosis risk for these patients, potentially delaying diagnosis.
Overdue
Wayne O’Neill
Concerns: The coroner noted a lack of recognition among clinicians regarding a specific medication's contraindication for asthma and the risks associated with a combination of psychotropic drugs. Concerns were also raised about the absence of routine ECG screening for prisoners prescribed this medication combination.
Response: • Routine annual ECGs are provided for patients prescribed anti-psychotic medication, particularly when combined with other medicines that increase the QT interval; this practice was in place prior to the … (AI summary)
Responded
Margaret Hions
Concerns: The coroner noted a need to review tinzaparin prescribing practices and blood level monitoring, alongside reiterating the importance of monitoring creatinine clearance according to Health Board policy.
Response (Margaret Hions): • A revised guideline for prescribing and monitoring low molecular weight heparin has been produced. • The importance of monitoring creatinine clearance is being reiterated by letter to clinicians and … (AI summary)
Responded
Ann Jacobs
Concerns: The coroner noted insufficient monitoring of potassium levels every 8 hours following a diagnosis of severe hypokalaemia and a lack of adherence to the Trust's acute hypokalaemia management guidance.
Overdue
Marjorie Bassendine
Concerns: The coroner noted concerns about the potential for multiple psychotropic medications to prolong the QT interval, highlighting the importance of pre-treatment and regular ECGs to monitor for long QT syndrome.
Response (RCPSYCH): • The Royal College of Psychiatrists stated it would liaise with its Special Committee for Psychopharmacology and Faculty of Old-Age Psychiatry to publicise and raise the identified issues. • The … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The report details were added to the Adverse Drug Reaction database. • The product information for olanzapine, mirtazapine, and indapamide was reviewed. • The issue will be kept under … (AI summary)
Overdue
Michael Mahon
Concerns: The coroner noted that Michael Mahon missed a required annual clozapine test in March 2016, and there was no system in place to identify that this test had been missed or to flag it during subsequent monthly checks.
Overdue
Amanda Spark
Concerns: The coroner noted a gap in communication where changes to a patient's mental health medication regime, supervised by the Crisis team, did not trigger corresponding action or review regarding their physical health medication.
Overdue
Astonn Mitchell-Male
Concerns: The Trust lacked a policy for monitoring patient medication compliance and triangulating information in community settings. There were also concerns about poor and non-existent record-keeping, impacting communication and patient safety.
Overdue
Chand Ali
Concerns: Cyclizine is routinely administered to heart failure patients without individual risk assessment, and there is no system to balance its risks against clinical need. The hospital does not monitor deaths following its use or review alternative antiemetics.
Response (Barts Health NHS Trust): • The Trust's lead pharmacist completed a review of the evidence for cyclizine use in severe heart failure and considered alternative anti-emetic drugs. • The Trust stated it would warn … (AI summary)
Responded
Megan Jones
Concerns: The coroner identified a lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding regular QTc recording, which is particularly crucial for those prescribed high doses.
Overdue
Nathan Cooke
Concerns: The coroner noted the absence of a formal process for primary care practices to manage patients prescribed medication requiring regular monitoring, particularly when patients do not attend reviews.
Overdue
Christopher Summerhayes
Concerns: The coroner raised concerns regarding the prescription of Clozapine alongside numerous other medications, leading to significant weight gain and potential cardiovascular issues, and the lack of consideration for familial lipid disorders that might contraindicate its use.
Response: • The Health Board confirmed that the death was reported to the Medicines and Healthcare products Regulatory Agency (MHRA) and detailed existing systems for Clozapine monitoring, polypharmacy reviews, and medicines … (AI summary)
Responded
Liane Davenport
Concerns: The coroner raised concerns regarding whether monitoring blood levels of powerful antipsychotics should be considered for patients on long-term high-dose treatment, particularly as they become older and more frail.
Response (St Nicholas Hospital): • The Trust reviewed the measures in place to ensure patients' physical health is sufficiently monitored when on long-term, high-dose antipsychotic treatment. • The Trust provided its policy detailing additional … (AI summary)
Overdue
Ivan O’Neill
Concerns: The patient was positioned out of sight from the nurses' station, and the dialysis equipment's alarm was insufficiently sensitive to promptly detect significant blood loss from a dislodged needle.
Overdue
Jamie Poole
Concerns: The coroner noted inconsistent routine testing of magnesium levels in transplant patients on tacrolimus across different NHS trusts, despite the known life-threatening side effect of reduced magnesium. This variability means patients may not be regularly monitored.
Response (NHS England): • A National Patient safety alert (Level 2) will be issued regarding the risk of severe hypomagnesemia in transplant recipients. • A Reminder Alert will be sent out on magnesium … (AI summary)
Responded
Ann Coles
Concerns: The coroner noted the absence of a requirement for regular lung imaging in patients prescribed long-term amiodarone, despite the medication's potential to cause lung toxicity and fibrotic changes.
Response (Royal College of General Practitioners): • The Royal College of General Practitioners stated that it is not a regulating organisation for medication. • The Royal College of General Practitioners noted that regulatory responsibility for medication … (AI summary)
Response (Royal College of Physicians): • The Royal College of Physicians stated that no new systems of monitoring and reporting are required for amiodarone prescription. • It recommended strict adherence to existing national NICE and … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The MHRA will improve the Patient Information Leaflet to highlight the seriousness of amiodarone-related pulmonary toxicity. • The MHRA will consider additional risk minimisation measures, including a Patient Alert … (AI summary)
Responded
Bruce Houghton
Concerns: The coroner noted that the deceased had not received an annual medication review, and that such reviews do not routinely include enquiries about over-the-counter medications taken alongside prescribed ones.
Response (GMCA): • The Greater Manchester Medicines and Guidelines Sub-group discussed the matter and identified key outcomes. • The case will be referred through Greater Manchester health and social care forums to … (AI summary)
Response (Uplands Medical Practice): • The Practice is developing a standardised medication review template to include a routine inquiry about over-the-counter medication and supplements. • The Practice will prioritise and complete structured medication reviews … (AI summary)
Response (Department of Health Social Care): • The Department of Health and Social Care brought the coroner's concerns to the attention of NHS England and NHS Improvement. • The response noted that Uplands Medical Practice introduced … (AI summary)
Responded
Steven Allen
Concerns: The coroner noted concerns regarding the prescribing of oxycodone and other medications to an individual with a history of addiction, especially when prescriptions were issued via telephone consultations and replacement prescriptions were given with little challenge.
Response (Stockport Clinical Commissioning Group): • The practice undertook a review of the case and its processes for managing prescribing for vulnerable patients. • The Medicines Management Team is discussing with Primary Care Network Leads … (AI summary)
Responded
Sarah Brady
Concerns: The coroner noted concerns regarding a hospital issuing a 14-day prescription for medication already prescribed by the GP, which contradicted the GP's practice of issuing 7-day prescriptions to a patient with a high overdose risk and erratic compliance. This additional prescription may have contributed to medication stockpiling.
Response (Sandwell General Hospital): • The hospital stated that medications were supplied for limited durations (7 or 5 days) or were not dispensed, with patients receiving their own medications. • The hospital noted that … (AI summary)
Responded
Donald Compton
Concerns: The electronic prescribing tool permitted bypassing allergy sections and there was insufficient knowledge of drug constituents, leading to prescribing errors. These issues were not identified by hospital staff during discharge or by a GP, including an Amiodarone dosage error.
Overdue
Malcom Garrett
Concerns: The coroner noted a lack of specific guidance for managing immunosuppressed patients at high risk of Covid-19 in a hospital setting, including expediting their discharge or exploring alternative treatments. There was also a need for greater monitoring of kidney function to prevent opiate toxicity.
Overdue
Eirwen Hollister
Concerns: The GP practice lacked a process to ensure a full review by a GP before issuing further prescriptions after a patient had overdosed on prescribed medication.
Response (NHS England): • Heathview Medical Practice updated its policy on managing hospital letters and conducted a teaching event for staff on read coding and urgent patient reviews. • Heathview Medical Practice produced … (AI summary)
Response (Heathview Medical Practice): • The practice provided a report following the inquest to prevent future deaths. • The practice provided a Significant Event Analysis. • The practice provided an Overdose Policy. (AI summary)
Overdue
Keith Dimond
Concerns: The coroner noted clinicians were unaware of a prior diagnosis, critical information was not shared with the patient and family on discharge regarding anticoagulant risks, and specialist advice on anticoagulation was not followed or documented.
Response (East Kent Hospitals University): • The Trust has implemented the Sunrise digital system to enhance the clarity and accessibility of medical records and is revisiting training for clinicians on its use. • The Trust … (AI summary)
Responded
Evelina Vilkiene
Concerns: The coroner identified gaps in risk assessment and management plans during the patient's transition between mental health teams and when medication was weaned. Further concerns included the absence of required care co-ordinator reviews for an amber zoned patient.
Response (North East London NHS Foundation Trust): • The Trust agreed to take actions to address the concerns raised. • The Trust stated that these actions would be detailed in an attached action plan. (AI summary)
Responded
Mohammed Hussain
Concerns: The coroner identified inadequate systems for monitoring and communicating high clozapine levels, and a lack of staff understanding in interpreting and responding to them. This included ineffective medication change processes and insufficient learning from previous concerns.
Response (Response Birmingham and Solihull Mental Health NHS Foundation Trust): • An urgent learning session has been put into place. • A recorded webinar on clozapine interpretation and action will be made available to all clinical staff. • A specialist … (AI summary)
Response (Response Medicines Healthcare products Regulatory Agency): • The MHRA issued a Drug Safety Update article in August 2020 advising monitoring of blood concentrations of clozapine for toxicity in certain clinical situations. • The MHRA will continue … (AI summary)
Responded
John James
Concerns: The coroner noted that the refusal of anti-coagulation medication was not brought to the attention of medical staff. There is no electronic prompt or alert to notify the medical team when prescribed anti-coagulation medication is not administered.
Response (Bart Health NHS Trust): • The Trust stated that its electronic prescribing system includes visual flags for delayed medication doses, and confirmed that Millennium training will be updated to ensure staff know how to … (AI summary)
Responded
Colin Greenway
Concerns: Concerns were raised regarding junior doctors' incorrect prescribing despite clear guidelines and inadequate VTE assessments. The coroner also noted consultants not accepting responsibility for monitoring junior doctors' prescribing, and a lack of continuity of care for patients.
Response (The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust): • The Trust removed local VTE guidelines from its intranet, replacing them with a link to NICE guidance, and distributed a VTE booklet to junior doctors. • Stickers were commissioned … (AI summary)
Responded
Amanda Kramer
Concerns: The coroner noted that Mrs Kramer was prescribed Zopiclone, a short-term medication, for 18 years without clear evidence of review by her GP or mental health trust, even following instances of high-risk behaviour.
Response (Wood Street Health Centre): • The Practice identified all patients prescribed Zopiclone or Zolpidem and initiated a review process to create plans for medication reduction or cessation. • Prescriptions for Zopiclone and Zolpidem were … (AI summary)
Response (North East London NHS Foundation Trust): • The Trust implemented a process for reviewing Zopiclone prescriptions for new and existing patients, supported by senior clinical oversight and a six-monthly audit. • Staff received training on the … (AI summary)
Response (Department of Health and Social Care): • The Royal Pharmaceutical Society was commissioned to provide a repeat prescribing toolkit. • An action plan was published in March 2023 to help local health care providers reduce inappropriate … (AI summary)
Responded
Teresa Bennett
Concerns: The coroner noted a lack of compliance with medication review targets in GP practices and no standard practice for reviews, leading to variation between clinicians. This raised concerns about the risk of inadvertent overdose when central nervous system depressants are co-prescribed without regular review or specific patient advice.
Response (Betsi Cadwaladr University Health Board): • Benchmarking work commenced on February 21, 2024, to identify patients requiring medication reviews, with completion by May 31, 2024, followed by risk stratification. • A pan-Health Board policy is … (AI summary)
Responded
Malcolm Garrett
Concerns: The coroner noted the absence of specific guidance for managing and expediting discharge of high-risk immunosuppressed patients in acute hospital settings. Concerns were also raised about insufficient monitoring of kidney function, which contributed to opiate toxicity and delayed discharge.
Response (Department of Health and Social Care): • The CQC obtained records and assurances from the Trust regarding the management of hospital-acquired COVID-19 risks and patient discharge. • The Trust identified learning and actions in response to … (AI summary)
Responded
Kelly Stevens
Concerns: The coroner identified a lack of overall consultant responsibility for a medical outlier patient and no Trust policy to address this. Concerns also included insufficient monitoring of electrolytes and fluid balance, and outdated care plans due to routine copying and pasting.
Response (Worcestershire Acute Hospitals NHS): • A policy for the management of medical outliers has been agreed and is scheduled for approval and implementation. • A Trust-wide "Lesson of the Week" was shared to improve … (AI summary)
Responded
Thomas Burroughs
Concerns: The coroner noted the acute Trust's protocol was not followed as no Datix report was raised for a split Hickman Catheter despite infection risk. The catheter also remained in situ for an extended period, even with signs of infection.
Response (Mid South Essex NHS Trust): • The Trust retrospectively reported the split Hickman catheter incident internally and to the Medicines and Healthcare Products Regulatory Agency (MHRA), with immediate learning identified and cascaded to staff. • … (AI summary)
Responded
Laura-Jane Seaman
Concerns: The coroner noted significant omissions in medical record-keeping and a failure to escalate Laura-Jane as a deteriorating patient in accordance with national guidance. Concerns were also raised about the miscategorisation of her collapse and the inadequate recognition of hypovolemia despite her expressed concerns.
Response (Royal College of Obstetricians and Gynaecologists): • The Royal College of Obstetricians and Gynaecologists (RCOG) develops and disseminates clinical guidance for the management of obstetric emergencies, including postpartum haemorrhage and maternal collapse. • The RCOG supports … (AI summary)
Response (Mid South Essex NHS Trust): • The Trust has implemented an electronic prescribing and medication administration (EPMA) platform and a new National MEWS package with an escalation policy across its maternity services. • Staff have … (AI summary)
Responded
William Northcott
Concerns: The coroner noted a disparity in monitoring and discussion of Clozapine side effects for patients attending GP practices compared to specialist clinics, highlighting this as a potential national issue. There was also insufficient focus on cardiomyopathies like left ventricular hypertrophy in Clozapine guidance, which is based on national recommendations.
Response (Devon ICB): • NHS Devon will provide additional funding to Devon Partnership NHS Trust in the 2025/26 financial year to support the implementation of more Clozapine clinics. • NHS Devon will ensure … (AI summary)
Response (Medicines and Healthcare Projects Regulation Authority): • The Medicines and Healthcare products Regulatory Agency (MHRA) is reviewing the product information for clozapine. • The review will consider how to improve the clarity of information provided to … (AI summary)
Response (Devon Partnership NHS Trust): • Devon Partnership NHS Trust established specialist Clozapine clinics for patient education and monitoring, and developed a business case to expand these clinics to cover all patients. • The Trust … (AI summary)
Response (The Pembroke Medical Practice): • The Practice withdrew from the agreement with Devon Partnership NHS Trust to provide phlebotomy services for clozapine monitoring. • The Practice ensured that all GPs and clinicians are aware … (AI summary)
Responded
Jacqueline Green
Concerns: Bedford Hospital had not adopted national safety observations from 2022 regarding paracetamol dosing for low-bodyweight patients. The electronic system lacks alerts for weight accuracy in paracetamol prescriptions, and practical steps for routine patient weighing are insufficient.
Response (Bedford Hospitals NHS Foundation Trust): • A pharmacy-led audit of IV paracetamol prescribing patterns was conducted, and a soft review prompt for IV paracetamol after 24 hours was introduced on Nervecentre. • Nervecentre prescribing alerts … (AI summary)
Responded
Louise Rosendale
Concerns: The coroner noted insufficient review and oversight of long-term opiate prescriptions for patients within the practice. There was also a significant delay between identifying a patient on such a prescription and the next planned action.
Response (Flixton Road Medical Centre): • The practice completed a comprehensive review of opioid prescribing, which led to a revised policy, mandatory prescriber training, and an audit of high-risk prescribing. • A robust process for … (AI summary)
Response (Greater Manchester Integrated Care): • The locality plans to work with GP practices to increase use of the Safety Medication (SMASH) dashboard, including a new opioid indicator. • A pharmacy technician and pharmacist will … (AI summary)
Responded
Select committee recommendations(2)
#17 —
Recommendation: NHSE told us that it is looking at interventions that could be done by other health care professionals in primary care. For example, enhancing the clinical service community pharmacists provide to include undertaking medication reviews for people with frailty.36 However, …
Response attribution not verified
#7 —
Recommendation: For all patients diagnosed with severe frailty, the GP contract requires GPs to do a clinical review. This includes a review of the patient’s medication, a falls risk assessment and a discussion with the patient of the benefits of having …
Response attribution not verified
HSSIB safety recommendations(30)
Potential under-recognised risk of harm from the use of propranolol
The Practice has limited repeat prescriptions for antidepressants to a three-month period and now limits prescription of propranolol to a 28-day supply for patients who also have depression.
Safety Action
Potential under-recognised risk of harm from the use of propranolol
The Practice developed new guidance for patients new to antidepressants. This prompts its GPs to arrange patient reviews at: two weeks, more frequently over the first three months, a three-month follow-up, and then a further follow-up in six to 12 …
Safety Action
Potential under-recognised risk of harm from the use of propranolol
Safety action by the Medicines and Healthcare products Regulation Agency (MHRA) The MHRA is reviewing the information in the Summary of Product Characteristics (a legally required document detailing a medicine’s properties and officially approved conditions of use) for propranolol-containing products …
Safety Action
Potential under-recognised risk of harm from the use of propranolol
Further research into possible interactions between propranolol and Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants in overdose would be beneficial.
Safety Observation
Potential under-recognised risk of harm from the use of propranolol
Electronic prescribing systems used in primary care may benefit from alerts that prompt clinicians about the potential risks of prescribing propranolol to people in certain patient groups.
Safety Observation
Medication not given: anticoagulation before and after a procedure
Does your ePMA system identify patients with paused time-critical medication that may warrant a review?
Learning Prompt
Medication not given: anticoagulation before and after a procedure
Does your organisation have systems and processes in place that support regular risk assessment of anticoagulants that have been paused?
Learning Prompt
Medication not given: anticoagulation before and after a procedure
How does your organisation support staff to identify and document decision making at critical decision points where anticoagulation should be reviewed?
Learning Prompt
Electronic prescribing and medicines administration systems and safe discharge
It is recommended that the Department of Health and Social Care should consider how to prioritise the commissioning of research on human factors and clinical decision support systems; particularly in relation to the configuration of software system alerting and alert …
Safety Recommendation
Procurement, usability and adoption of ‘smart’ infusion pumps
British National Formulary
Learning Prompt
Never events: analysis of HSIB's national investigations
Prescribing and administering insulin from a pen device in hospital (Healthcare Safety Investigation Branch, 2019c).
Learning Prompt
Potential under-recognised risk of harm from the use of propranolol
The Ambulance Trust has recognised the limitation of the local variation to its call handling policy and raised a case with the AMPDS dispatch academy to ask that propranolol be added to the list of medicines within AMPDS that can …
Safety Action
Potential under-recognised risk of harm from the use of propranolol
The Practice carried out an audit of all patients on antidepressants and invited them for a review appointment. The Practice now sends text/call reminders to patients who do not attend appointments and also have depression.
Safety Action
Potential under-recognised risk of harm from the use of propranolol
Safety action by NHS England/NHS Improvement In March 2019, NHS England wrote to ambulance trusts in England regarding the management of cases where patients have self-harmed and are at risk of suicide. This included specific reference to patients who may …
Safety Action
Potential under-recognised risk of harm from the use of propranolol
National resuscitation guidance may benefit from further specific information concerning the additional challenges and treatment options available for other types of medication overdose.
Safety Observation
Potential under-recognised risk of harm from the use of propranolol
It is recommended that the National Institute for Health and Care Excellence reviews and updates guidance on the use of propranolol in the treatment of anxiety and migraine, with particular reference to the toxicity of propranolol in overdose.
Safety Recommendation
Potential under-recognised risk of harm from the use of propranolol
It is recommended that the British National Formulary reviews and updates guidance on the use of propranolol in the treatment of anxiety and the advice provided for beta blocker overdose.
Safety Recommendation
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors …
Caring for older patients in hospital often presents a high-risk situation for medication errors occurring. Further efforts should be made to learn from technological developments and the organisation of pharmacy services in other high-risk areas of care that may improve …
Safety Observation
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors …
Clinical pharmacy services should consider using validated tools to assist in prioritising pharmacy care and identifying high-risk medicines and high-risk situations for medication error. Where electronic medical record systems are used, such tools could be integrated into these systems to …
Safety Observation
Procurement, usability and adoption of ‘smart’ infusion pumps
Specialist Pharmacy Service • Safe Anaesthesia Liaison Group
Learning Prompt
Procurement, usability and adoption of ‘smart’ infusion pumps
MEDUSA (UK Injectable Medicine Guide)
Learning Prompt
Residual drugs in intravenous cannulae and extension lines
This is particularly the case for drugs that can cause a clinically significant effect in low volumes.
Learning Prompt
Residual drugs in intravenous cannulae and extension lines
One of the key risk factors associated with residual drugs in cannulae and extension lines is the concentration and risks associated with the drug itself.
Learning Prompt
Unintentional overdose of paracetamol in adults with low bodyweight
It may be beneficial for electronic prescribing and medication administration systems to include an alert for oral paracetamol that prompts documentation of a patient’s weight and consideration of the risk of liver toxicity when their weight is less than 50kg.
Safety Observation
Assessment of risk during the maternity pathway
the safe use of prostaglandins or oxytocin
Learning Prompt
Potential under-recognised risk of harm from the use of propranolol
The Practice now schedules patient reviews at 12-month intervals in advance for patients with mental health needs.
Safety Action
Insulin: supporting safe self-administration for patients in the community with a mental health problem
Organisations involved in the provision of undergraduate and pre-registration education and preceptorship/induction programmes can improve patient safety by ensuring that staff have knowledge of diabetes, an understanding of how and why insulin is a vital treatment for many people with …
Safety Observation
Potential under-recognised risk of harm from the use of propranolol
It is recommended that PrescQIPP CIC supports its subscribers to identify the potential risk of prescribing propranolol to patients in at-risk groups.
Safety Recommendation
Potential under-recognised risk of harm from the use of propranolol
It is recommended that the Royal Pharmaceutical Society supports its members in identifying the potential risk of prescribing propranolol to patients in at-risk groups.
Safety Recommendation
Potential under-recognised risk of harm from the use of propranolol
It is recommended that the Royal College of General Practitioners supports its members in identifying the potential risk of prescribing propranolol to patients in at-risk groups
Safety Recommendation
NCEPOD recommendations(3)
CQC inspection actions(30)
Worthing Hospital
The trust must ensure the Patient Group Directive treatment of neutropenic patients is reviewed in a timely manner.
Must Do
King George Hospital
The service must ensure that staff follow policy to identify and document patients who are on time critical medicines.
Must Do
Hemel Hempstead General Hospital
The trust should ensure medicines are managed in line with guidelines. The trust should ensure that antibiotic prescriptions clearly record review dates and ensure that patients weights are clearly recorded.
Should Do
Ellesmere Port Hospital
The trust should review the prescribing of medicines that control distressed behaviour to ensure the policy is followed and monitoring is completed.
Should Do
The Walton Centre
The service should ensure it continues to monitor and improve the management of controlled drugs. (Regulation 12)
Should Do
The Sidings Medical Practice
Improve the process for the monitoring of patients in receipt of high-risk medication.
Should Do
St Helens Hospital
Continuetomonitorpatientmedicationreviews.
Should Do
Penn Manor Medical Practice
Continuetomonitorandreassurethemselvesthatcliniciansarefollowingtheproceduresandguidanceinplaceforthereviewofpatientsprescribedhighriskmedicines
Should Do
Penn Manor Medical Practice
Continuetoimprovethemonitoringandreviewofpatientsprescribedhighriskmedicines.
Should Do
Moorcroft Medical Centre
Evaluate and embed the changes implemented during the inspection. For example, older medicine safety alert system searches, monitoring and coding systems for prediabetes patients and the reintroduction of downloading electronic pathology results prior to repeat prescribing.
Should Do
Birmingham Children's Hospital
The trust should consider implementing a process to monitor the use of sedation or rapid tranquilisation, to be assured that administration is in line with policy, not excessive and appropriate.
Should Do
Andover War Memorial Hospital
The service should ensure there is effective governance and analyse of the risk for the anaesthetic medicines within the unit.
Should Do
Charlton House Medical Centre
Arrangements for monitoring patients prescribed high risk medicines continued to place patients at risk of harm.
Must Do
Royal Hallamshire Hospital
The trust must ensure staff undertake and record appropriate observation of service users’ health after administering rapid tranquilisation.
Must Do
Queen's Hospital
The service must ensure that staff follow policy to identify and document patients who are on time critical medicines.
Must Do
Northern General Hospital
The trust must ensure that staff follow systems and processes to prescribe and administer medicines safely.
Must Do
Northern General Hospital
The trust must ensure staff undertake and record appropriate observations of service users’ health after administering rapid tranquilisation.
Must Do
Montagu Hospital, Mexborough
ThetrustshouldensureastandardoperatingprocedureisdevelopedforthemanagementofFentanyluseasbolusdoses.
Should Do
Kettering General Hospital
The servicemust ensure the proper and safe management of medicines. This includes but is not limited to ensuring medication is correct and appropriate to the patient’s situation and needs; ensuring staff follow policies and procedures in managing medicines; weights are …
Must Do
Ellesmere Port Hospital
The trust must ensure there are effective systems in place for the safe management, storage, and monitoring of medicines. The system must ensure the safe administration of medicines including medicines administered covertly.
Must Do
Ellesmere Port Hospital
The trust must ensure that oxygen is prescribed as required by national guidelines.
Must Do
Ellesmere Port Hospital
The trust must ensure there are effective systems in place for the safe management, storage, and monitoring of medicines. The system must ensure the safe administration of medicines.
Must Do
Victoria Infirmary
The service should take actions to improve antimicrobial prescribing compliance and improve the safest storage of medicines.
Should Do
Verve Health
The service must ensure that service users undergoing medical detoxification are appropriately monitored during their detox programme, including respiration rates and temperatures.
Must Do
Salford Royal Hospital
The trust should ensure emergency medicines checks are completed.
Should Do
Doncaster Royal Infirmary
The trust must ensure staff follow the proper and safe management of medicines, and the service uses systems and processes to prescribe and administer medicines safely.
Must Do
Chorley and South Ribble Hospital
The trust should monitor and review arrangements to ensure that medicines with a minimum dosage interval are administered as prescribed.
Should Do
Chorley and South Ribble Hospital
The trust should monitor and review arrangements to ensure that medicines with a minimum dosage interval are administered as prescribed.
Should Do
Taplow Manor
The provider must ensure young people receive physical health observations following the use of rapid tranquilisation in accordance with national guidance and the providers policy.
Must Do
Dr Jude's Practice - Riverside & Picton
Continue to monitor and provide evidence of effective medicines reviews for patients on repeat medicines.
Should Do
PPO death in custody recommendations(9)
Manx Care
Manx Care should ensure that patients who come in with complex and high-risk medication (as per the RCGP guidance) have a medication review when they arrive at the prison.
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.
The Head of Healthcare
there is an in-possession policy in place, to identify whether a prisoner is able to have weekly or monthly prescriptions in possession which includes vigorous risk assessment, compliance monitoring with the medication regime and random cell checks to count medications.
The Head of Healthcare
there is a system in place to monitor use of glucose tablets and overuse should prompt a diabetic medication review; and
The GP Lead at HMP Exeter
The GP Lead at HMP Exeter should review prescribing processes to ensure high-risk medication assessments are completed in a timely way, with consideration of the impact on the individual
The Head of Healthcare at HMP Wandsworth
The Head of Healthcare should incorporate closer healthcare observations for prisoners who are on a reduction regime and/or are being taken off Gabapentinoids, to monitor withdrawal symptoms and any adverse effects.
The Head of Healthcare
The Head of Healthcare should ensure that the prisoner’s history and risk factors for suicide and self-harm are taken into account in medication in-possession risk assessments.
The Head of Healthcare
The Head of Healthcare should review the treatment policy and management of methadone, including assessing the need for ECG tests when starting methadone and additional monitoring when dosage is significantly increased.
The Head of Healthcare at HMP Wandsworth
The Head of Healthcare should ensure that the prescribers have a face-to-face conversation with a prisoner if there is an intention to reduce or cease any high risk prescribed medication.
National patient safety alerts(6)
Valproate: new regulatory measures for prescribing oversight
Nov 2023
NatPSA/2023/013/MHRA
Risk of oxytocin overdose during labour and childbirth
Sep 2024
NatPSA/2024/010/NHSPS
Reducing risks for transfusion-associated circulatory overload (TACO)
Apr 2024
NatPSA/2024/004/MHRA
Inappropriate dosing risk when switching insulin degludec (Tresiba) products
Dec 2023
NatPSA/2023/016/DHSC
Potential risk of underdosing with calcium gluconate in severe hyperkalaemia
Jun 2023
NatPSA/2023/007/MHRA
Harm from delayed administration of rasburicase for tumour lysis syndrome
Sep 2025
NatPSA/2025/005/NHSPS
Health investigations(84)
Independent investigation: WPC Nina Mackay, Stratford, London (1997) — Rec 2
The Royal College of General Practitioners, the Royal College of Psychiatrists, the Royal Pharmaceutical Society and the UKCC should issue joint clinical guidance and professional practices on the prescribing, dispensing and monitoring of self-administered medication for people with severe and enduring mental illness. This should include guidance on the implications …
london
Independent investigation: Michael Kahan, Manchester (2008) — Rec 1
The Trust should ensure that when a patient is suspected of not conforming with Clozapine treatment steps are taken to determine compliance. This should include: Serum/therapeutic level testing; carer involvement/consultation; service user engagement; clinical presentation; mental state examination.
north_west
Independent investigation: Eileen Cameron, Reading, Berks (1997) — Rec 19
that consideration is given to linking this development with the development of a depot clinic and a lithium clinic.
south_east
Independent investigation: Eileen Cameron, Reading, Berks (1997) — Rec 18
that, in line with the Cambridge model, a. the trust’s pharmacy department takes over control of Clozaril prescriptions, which are limited to 28 days at a time; b. a Clozaril clinic is set up, which is staffed by a dedicated community psychiatric nurse (to assess the patient’s mental state) and …
south_east
An independent investigation into the care and treatment of mental … — Rec 2b
The Trust and NHS Manchester CCG must develop and agree guidance for GPs on the administration of clozapine and the limited function of blood tests for titration.
Greater Manchester Mental Health NHS Foundation Trust
north_west
An independent investigation into the care and treatment of mental … — Rec 2a
The Trust must provide clear guidelines for risk assessment and care planning for the titration of clozapine in the community.
Greater Manchester Mental Health NHS Foundation Trust
north_west
Independent investigation: Warren Duke, Slough (but Tees patient) (2015) — Rec Recommendation 2
TEWV must review the EIPT operational policy to set out agreed methods and expectations around multidisciplinary working, to ensure that senior medical staff are involved appropriately in discussions about patients where staff have concerns, and at least annually, where patients are receiving antipsychotic medication.
north_east_yorkshire
Independent investigation: Tyler Warmington, Faringdon, Oxon (2017) — Rec 7.5
We note that steps have been taken by the Trust to review and refresh their shared care protocol for the management of patients taking Lithium and that steps have also been taken to ensure that information about risk is communicated effectively. We recommend that an audit be undertaken of a …
south_east
Independent investigation: Thomas Abraham, Gloucester (2019) — Rec 1
Clozapine management: Trusts should ensure staff understand the fundamental elements of clozapine management, including service user capacity, consent, risk management and individual responsibilities. This should be underpinned by up-to-date policy, training, and a review of all clozapine patients to ensure their management is undertaken in line with expected practice.
south_west
Independent investigation: Suryakant Patel, Harlington, London (2006) — Rec 3
One of the relapse triggers for the MHSU was medication non-compliance and on numerous occasions staff underlined for the MHSU the absolute importance of taking his medication. However, at some times the MHSU took only very low doses of his medication and his care coordinator, an occupational therapist (OT), and …
north_east_yorkshire
Independent investigation: Stephen O’Brien, Crewe (2016) — Rec 3
The Trust should develop a protocol to support clinicians on when to decide to use depot antipsychotic medication in patients with active psychosis who are unable to dependably use oral antipsychotics.
north_west
Independent investigation: Rodney Wells, Nottingham (2006) — Rec R2
The trust should review the shared care protocol for atypical antipsychotic drugs to clarify whether patients other than those with diagnoses of schizophrenia and related disorders and bipolar disorder who receive such medication should be subject to the protocol. The review should also consider whether doctors other than the patient’s …
midlands
Independent investigation: Remy Surage (Mr S), Orpington, Kent (1998) — Rec 7.1.1
Where patients are known to have difficulty in complying with prescribed medication staff should ensure that regular, rigorous and appropriate monitoring of medication takes place and is recorded.
south_east
Independent investigation: Paul Taylor, Jarrow (2019) — Rec 7
Care coordinators must initiate a discussion with the Consultant Psychiatrist to assess whether a formal medication review is required when there is a crisis and serious risk of harm to self.
north_east_yorkshire
Independent investigation: Paul BrownDorothy Brown, Liverpool (2014) — Rec 7
There should be a Trust wide policy on prescribing high dose antipsychotic medication which includes standards for auditing, which should be in line with the Royal College of Psychiatrists guidelines
north_west
Independent investigation: Linda Goswell, Cygnet hospital, Bradford (2014) — Rec 7
Cygnet Health Care should ensure that hospitals comply with the policy on routine monitoring of physical healthcare checks for patients on anti-psychotic medication.
north_east_yorkshire
Independent investigation: Leslie Brown, Warrington (2006) — Rec 1
It is recommended that 5 Boroughs Partnership NHS Foundation Trust commissions an audit across its adult services to determine the reliability with which service users are monitored appropriately following a change from depot anti-psychotic medication to an oral equivalent. The Independent Team suggests that the data fields and scope of …
north_west
Independent investigation: Kenneth Auger, Merthyr Tydfil (2008) — Rec 3.4r
Review and audit the processes in place for medication monitoring in primary care, in particular the processes used for the purposes of monitoring Lithium levels in mental health service users in line with National Patient Safety Agency (NPSA) guidelines10.
wales
Independent investigation: John TaylorBeverley Taylor, Skipton (2021) — Rec 12
The monitoring of Patient E’s medication, efficacy, side effects and his compliance was not adequate. • The Trust must ensure that services users on anti-psychotic medication are monitored at appropriate intervals for side effects using the appropriate methods (e.g. LUNSERS or monitoring blood results) and the services user’s condition is …
north_east_yorkshire
Independent investigation: James Fortey, Newport, Gwent (2007) — Rec 6
In order to maximise and encourage patients’ compliance with medication regimes, Primary and Secondary Care services should ensure good communication and ensure that medication reviews are undertaken regularly, with patient involvement.
wales
Independent investigation: Colin Anderson, Newcastle (2006) — Rec 4
Where GPs are managing patients with mental health problems without involvement of secondary services, it is essential that long running prescriptions of medication – especially benzodiazepines – are regularly reviewed in face to face appointments. Where new medication has been introduced, or doses significantly altered, reviews should be arranged to …
north_east_yorkshire
Independent investigation: Carl Scott, Winchester — Rec 4
At times of high risk e.g. a change of antipsychotic medication consideration should be given to placing the service user on shared care . This to be subject to annual audit.
south_east
Independent investigation: Jean Robertson, Sittingbourne (2015) — Rec 6
The Trust must assure themselves and their commissioners that the provision of six-monthly reviews to patients in receipt of clozapine is embedded in every-day practice.
south_east
Independent investigation: Chloe Sutherland (8 mnths), Edinburgh (2015) — Rec 9
Ensure that patients treated with antidepressants are reviewed in line with NICE and local good practice guidance.
scotland
Independent investigation: Brian Dodd, Prestatyn (2003) — Rec a)
That Cardiff and Vale NHS Trust ensures there are robust mechanisms in place to monitor the compliance of conditionally discharged patients in taking oral medication.
wales
*Mental health homicide investigation legacy report into the care and … — Rec 1
The Trust should ensure there is guidance in place detailing the responsibility of clinicians to ensure that service users are monitored during changes to psychiatric medication and have process in place to monitor adherence to this on an ongoing basis.
south_east
Independent review of the care and treatment of Mr G — Rec 4
Side effect monitoring should be regularly undertaken and assessed as part of the care plan in place.
Mr G published on the 16 th November 2021. Mr G was in receipt of services from Barnet, Enfield and Haringey Mental Health NHS Trust
london
Accepted
Independent investigation into the care and treatment of Mr J — Rec 3
The Trust and NHS Newham CCG should develop guidelines for the integrated care and treatment of bipolar disorder across primary health and secondary mental health services, which includes guidance for GP’s action with regards to uncollected prescriptions in patients under secondary mental health care.
Mr J who committed a homicide in 2014. Mr J was in receipt of services from South London and Maudsley NHS Foundation Trust
london
Accepted
An independent review of the internal investigation and associated action … — Rec 6
The Trust must assure themselves and their commissioners that the provision of six-monthly reviews to patients in receipt of clozapine is embedded in every-day practice.
south_east
Accepted
An independent review of the care and treatment received by … — Rec R8
The trust should review its approach to medicines management/optimisation, particularly for those patients who are non-compliant with their atypical antipsychotic medication. This should include working towards a system of reinitiating atypical antipsychotics (such as clozapine) in the community, with 24-7 access to rapid screening tests and results. The trust should …
north_east_yorkshire
An independent quality assurance review of the implementation of recommendations … — Rec 3
The Trust should consider, and reference in appropriate policies, the need for additional methods of monitoring compliance with Lithium to mitigate the risks of non-concordance with treatment plans for patients with a history of non-compliance and who are at risk of relapse.
north_east_yorkshire
An independent inquiry into the care and treatment of S: … — Rec 7
There should be a Trust wide policy on prescribing high dose antipsychotic medication which includes standards for auditing, which should be in line with the Royal College of Psychiatrists guidelines
Mersey Care NHS Foundation Trust
north_west
An independent external quality assurance review (published 20 December 2018) … — Rec 6
There should be a trust wide policy on prescribing high dose antipsychotic medication which includes standards for auditing which should be in line with the Royal College of Psychiatrists guidelines.
north_west
Joint Safeguarding Adult Review and Independent Mental Health Homicide Investigation, … — Rec 17
The GP Practice, within six months of this report, should provide assurance that any existing patients with long-term prescription of benzodiazepines have been reviewed and documented in line with NICE guidance. This should include introducing a method for future identification and review of new patients.
london
Accepted
Independent investigation report into the care and treatment of Mr … — Rec 6
The Trust must assure itself and its commissioners that medications are prescribed in accordance with best practice and that timely reviews of the ongoing appropriateness of the dose are undertaken.
midlands
Independent investigation report into the care and treatment of Mr … — Rec 5
The Trust must ensure that appropriate action is taken when a clinician has advised that a review of a patient’s medications is required.
midlands
Independent investigation into the care and treatment of Mr H — Rec 9
NHS Merton/Wandsworth CCG should work with GP practices to ensure robust structures, processes and systems are in place to identify and manage (incidents) where patients on long term antipsychotic prescriptions default with prescriptions.
london
Accepted
Independent investigation into the care and treatment of Mr F: … — Rec 7
Both primary and secondary health care services should be considering the possible psychological effects and the potential for misuse of prescribed medication in patients with chronic or ongoing physical health issues. This issue should be considered within the patient’s mental health risk and care planning.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation into the care and treatment of Mr DB: … — Rec 6
Pennine Care NHS Foundation Trust, Stockport CCG : implement a system for follow up and monitoring of GP physical health checks re psychiatric medication
Mr DB . At the time of homicide December 2014 Mr DB was receiving care and treatment from Pennine Care NHS Foundation Trust
north_west
Independent external quality assurance review in respect of mental health … — Rec 8
Ensure that staff recognise poor concordance with medication as an indicator of risk and that non-concordance is incorporated into the risk management plan of the care programme approach.
NHS England, to review the outcomes of the Birmingham and Solihull Mental Health NHS Foundation Trust
midlands
Independent external quality assurance review in respect of mental health … — Rec 4
Develop a protocol for monitoring medication in line with the policy, that can review actions and risk against concordance.
NHS England, to review the outcomes of the Birmingham and Solihull Mental Health NHS Foundation Trust
midlands
Independent external quality assurance review in respect of mental health … — Rec 25
Implement a clear protocol for monitoring medication concordance for people who are considered to require sustained (long-term) treatment with antipsychotic medication.
NHS England, to review the outcomes of the Birmingham and Solihull Mental Health NHS Foundation Trust
midlands
Independent external quality assurance review in respect of mental health … — Rec 16
Development of medication monitoring protocol.
NHS England, to review the outcomes of the Birmingham and Solihull Mental Health NHS Foundation Trust
midlands
Independent Assurance Review – Mr X — Rec 3
The Trust and CCGs need to develop a shared protocol for the oversight and escalation of medication collection and compliance for patients assessed to be at increased risk.
london
An independent investigation into the care and treatment of patient … — Rec 12
The monitoring of Patient E’s medication, efficacy, side effects and his compliance was not adequate. • The Trust must ensure that services users on anti-psychotic medication are monitored at appropriate intervals for side effects using the appropriate methods (e.g. LUNSERS or monitoring blood results) and the services user’s condition is …
north_east_yorkshire
An independent investigation into the care and treatment of Patient … — Rec 7
Cygnet Health Care should ensure that hospitals comply with the policy on routine monitoring of physical healthcare checks for patients on anti-psychotic medication.
north_east_yorkshire
An independent investigation into the care and treatment of Ms … — Rec 3
1. The prescription of sodium valproate by clinicians should follow the recommendations within the British National Formulary, and the guidance from the Medicines and Healthcare Products Regulatory Agency, with respect to women of childbearing age. 2. In the event of the exceptional circumstances arising in which sodium valproate may be …
north_east_yorkshire
An independent investigation into the care and treatment of Ms … — Rec 7
Care coordinators must initiate a discussion with the Consultant Psychiatrist to assess whether a formal medication review is required when there is a crisis and serious risk of harm to self.
north_east_yorkshire
An independent investigation into the care and treatment of Mr … — Rec 1
The Trust should evaluate the senior primary care mental health nurse practitioner role in south east Essex to establish whether it has facilitated the management of depot medication and mitigated the risk of patients not receiving it.
east_of_england
An independent investigation into the care and treatment of mental … — Rec Recommendation 5
TEWV must review the TEWV CPA policy to ensure that overdue depot medication is communicated effectively in referral procedures and correspondence, e.g. by ‘phone.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Scottish Fatal Accident Inquiries(2)
Erin Casey and Christina Fiorre Ilia
I recommend the following:- (1) The vast majority of patients with epilepsy, or their parents or carers where appropriate, should be advised of the risk of SUDEP on first diagnosis or if , in the particular circumstances of that patient, there are exceptional circumstances for delaying immediate provision of the information, then within a very short time thereafter. Advice about …
Aug 2011
Stephen Masson
The sheriff having considered the information presented at the Inquiry, in terms of section 26(1)(b) of the Act, in having regard to matters mentioned in section 26(4) of the Act recommends that: (1) A note of all ongoing prescriptions currently prescribed to a patient should be registered with the NHS regardless of the prescriber to allow healthcare professionals immediate access …
Mar 2023
Article 2 learning points(1)
PHSO casework decisions(16)
P-002632 — Royal Devon University Healthcare NHS Foundation Trust
Mr H complained the Trust's paediatrician mismanaged his grandson's medication and lacked leadership, causing his mental health to deteriorate.
NHS in England
May 2024
P-002749 — North West Anglia NHS Foundation Trust
Miss U complained the Trust failed to regularly monitor and control her father's iron levels for years and failed to provide IV albumin during an ascitic drain procedure.
NHS in England
Partly Upheld
Jul 2024
P-003749 — Ashford and St Peter's Hospitals NHS Foundation Trust
Mrs O complained the Trust's inadequate blood monitoring and missed opportunities during scans led to her miscarriage and emotional distress.
NHS in England
Aug 2025
P-004025 — Stockport NHS Foundation Trust
Mrs P complained the Trust failed to prescribe her husband blood thinning medication before discharge after surgery, leading to a blood clot, thromboembolism, and his death.
NHS in England
Sep 2025
P-004503 — Bedfordshire Hospitals NHS Foundation Trust
Mrs F complained her husband missed liver follow-ups and had medication stopped, leading to an ulcer and death. She also alleged poor communication about his condition and missed final moments.
NHS in England
Partly Upheld
Dec 2025
P-001476 — Oxford University Hospitals NHS Foundation Trust
Mr O complained the Trust failed to appropriately monitor and manage his wife's diabetes after knee surgery, resulting in dangerously high blood sugar levels that contributed to her death.
NHS in England
Jun 2022
P-001704 — A practice in the Cheshire West and Chester …
Mr L complained GPs failed to monitor his father's blood pressure, wrongly changed medication, and provided poor complaint responses. He believed this contributed to his father's death.
NHS in England
Partly Upheld
Jan 2023
P-002480 — Manchester University NHS Foundation Trust
Mr C complained the Trust prescribed steroids for an eye condition without informing him of all possible side effects, leading to a mental health episode.
NHS in England
Upheld
Nov 2023
P-003495 — East Sussex Healthcare NHS Trust
Miss I complained the Trust failed to operate on her broken wrist, failed to diagnose hip/pelvis fractures, and gave her excessive medication, causing ongoing pain and health issues.
NHS in England
Apr 2025
P-003648 — Royal Devon University Healthcare NHS Foundation Trust
Mr A complained the Trust failed to consider all his symptoms, monitor his blood appropriately, and follow an appropriate medication plan for his complex hypothyroidism, leading to distress.
NHS in England
Jul 2025
P-004325 — University Hospitals Birmingham NHS Foundation Trust
Complaint alleged inappropriate treatment of pregnancy-induced hypertension, inadequate monitoring, failure to administer epilepsy medication, and sterilisation performed without informed consent during childbirth.
NHS in England
Upheld
Nov 2025
P-001663 — Manchester University NHS Foundation Trust
The Trust's rheumatology department failed to offer support or monitoring for medication, a nurse did not help with side effects, a doctor was dismissive, and the Trust delayed its complaint response.
NHS in England
Dec 2022
P-002906 — North Bristol NHS Trust
Mr U alleged the Trust failed to administer blood thinners to his wife, leading to a fatal blood clot, and also cited issues with consent, surgery delays, and communication.
NHS in England
Aug 2024
P-003221 — University Hospital Southampton NHS Foundation Trust
Mrs F complained her father received excessive warfarin and faced delayed CT scans after a fall, worsening a brain bleed and contributing to his death. She also cited a lack of fall prevention improvements.
NHS in England
Not Upheld
Dec 2024
P-004074 — A practice in the West Berkshire area
Mrs H complained her brother's GP failed to monitor his Atorvastatin use and blood pressure, and did not refer him for persistent UTIs, contributing to his death.
NHS in England
Sep 2025
P-004458 — Birmingham Women's and Children's NHS Foundation Trust
Mr B complained about his son P's mental health care, citing issues like discharge without transport, medication problems, lack of therapy, and poor transition to adult services.
NHS in England
Dec 2025
Domestic Homicide Reviews(31)
Gloucester — recommendation 2
NHS England to ensure that, at regional and national level, patients with severe mental health issues (such as schizophrenia) requiring regular antipsychotic medication have clear and specific care plans that identify their regular medication needs. This information must be contemporaneous and should be visible across all healthcare systems, including prison, …
NHS England
NHS England
Somerset — recommendation 7.2.5
When someone with complex presentation does not return initial attempts to make contact for a medication review that may impact on the risk that person may be exposed to as a result of lack of the review, further attempts to establish contact should be evidenced by the GP practice.
NHS Somerset ICB
NHS Somerset ICB
Buckinghamshire — recommendation ORB-5
It is therefore recommended that bloods should ideally be taken prior to commencing Espranor and if not possible then taken a soon as possible after prescribing is initiated.
One Recovery Bucks (Midlands Partnership NHS …
Buckinghamshire — recommendation GP3-2
To review the systems in place that alert the GP Practice to Out of Hours, and vice versa, of each other prescribing and risk monitoring to ensure that there is not over-prescribing, particularly of medication that can lead to addictions.
GP Practice 3
Buckinghamshire — recommendation GP3-1
To develop GP awareness of drug seeking behaviours and ensure that they are alert to the risk of addictions for patients being prescribed opioid medication, considering referrals to One Recovery Bucks before prescribing where there is a history of drug use. If alternative pain relief is not issued, to ensure …
GP Practice 3
Merton — recommendation 1
The SlaM Clinical Policy Working Group commission a discrete Trust-wide policy on clozapine monitoring, management and prescribing. This will help inform local protocols and best practice in both inpatient and community settings. It should include the following based on the learning from this incident: • Titration protocols • Registration with …
South London and Maudsley NHS Foundation …
South London and Maudsley …
Stockport — recommendation 6
For Pennine Care NHS Foundation Trust, Stockport CCG : implement a system for follow up and monitoring of GP physical health checks re psychiatric medication
Pennine Care NHS Foundation Trust | …
Pennine Care NHS Foundation …
Sandwell — recommendation 4
That, in order to improve safe practice and patient care, the Safer Sandwell Partnership asks NHS England, Birmingham, Solihull and Black Country Area Team to remind all GPs practices of the potential risks of repeat prescribing protocols, particularly for patients with mental health issues. To support and inform best practice …
NHS England, Birmingham, Solihull and Black …
Sandwell — recommendation 2
The practice to review their repeat prescribing protocol in respect of antidepressant prescribing to include requirements for periodic medication review to ensure that the patient receives effective treatment.
Sandwell and West Birmingham Clinical Commissioning …
Birmingham Clinical Commissioning Group
Southend-on-Sea — recommendation 9
The Clinical commissioning groups across SET to raise awareness of the 2019 Public Health England report on Prescribed medicines “Dependence and withdrawal of some prescribed medicines” and the recommendations contained within. To also ensure a process is put in place to obtain regular progress reports from the Director overseeing the …
Clinical commissioning groups across SET
Southend-on-Sea — recommendation 4
All GP practices across SET, should be moving to electronic prescribing which has functionality for prescriptions to be tracked; this should be embedded as a routine check for all claims of lost prescriptions especially for vulnerable patients and drugs that can cause dependency/abuse. (The CCG medicines management team can support …
NHS Southend ICB
Isle of Wight — recommendation 6.13
NHS England and the North Hampshire Clinical Commissioning Group should ensure that primary care providers undertake proactive medication reviews with all patients especially those who have added vulnerabilities or who have demonstrated poor compliance.
NHS England | North Hampshire Clinical …
NHS England
Tendring — recommendation 2
The GP surgery should have a clearly documented process in place that identifies medication risk and initiate appropriate and proportionate medication reviews, in accordance to the identified risk and its complexity.
Anglian Community Enterprise
Anglian Community Enterprise
Kingston upon Thames — recommendation 12
The practice should review its serious mental illness register 6 monthly to audit the ongoing support and medication required for those patients and whether mental health clinicians have been involved or need to be.
Perpetrator's GP Practice
Kingston upon Thames — recommendation 11
Where a patient on the serious mental illness register suddenly disengages from a service, such as ceasing to collect repeat prescriptions of essential medication, or failure to attend reviews, processes should be put in place to contact the patient for review as quickly as possible. An escalation policy should be …
Kingston Clinical Commissioning Group
Bristol Clinical Commissioning Group
Kingston upon Thames — recommendation 8
All patients on long term anti-psychotic medication should be clearly flagged on their patient record by their GP for annual review by mental health services and a referral triggered annually. This information should be on the Emis IT system, and if a patient is being prescribed medication by mental health …
Kingston Clinical Commissioning Group
Bristol Clinical Commissioning Group
Ealing — recommendation 38
When prescribing antiviral medication (such as Peginterferon) which has documented side effects of inducing psychiatric disorders, a specific verification from the patients GP concerning any mental health concerns should be obtained.
Imperial College Healthcare NHS Trust (St …
Wiltshire — recommendation 8.5.2
Patients who have previously overdosed should be searched for on the clinical system and a screen note added to their notes to act as a reminder prompt for the GPs when consulting with these patients.
Salisbury Plain Health Partnership
Wiltshire — recommendation 8.5.1
GPs should be reminded re the risk of prescribing amitriptyline when there is a risk of overdose.
Salisbury Plain Health Partnership
South Worcestershire — recommendation 17
All GPs within Worcestershire to be made aware of this incident and that change to medication may have impacted on this patient’s impulsivity and agitation. For GPs to be provided with information of how to access advice from the CARS team for complex patients/frequent changes to anti-depressant medications.
Herefordshire and Worcestershire Health and Care …
Herefordshire and Worcestershire Health …
Haringey — recommendation R1
GPs to be reminded to be vigilant when prescribing medications that started from hospital, especially when the patient has a forensic history
Islington ICB
Sunderland — recommendation SCCG-3
To promote and monitor implementation of best practice in prescribing management in relation to anti-depressants.
Sunderland Clinical Commissioning Group
Brent — recommendation 6.6.2
That when veterans or other clients report at the telephone triage or any point during treatment that they have recently stopped or changed their medication, the resulting changes in symptomatology (eg re-emergence of sleep patterns) should be explored and reviewed with the client and their GP should be made aware …
South West London and St George’s …
South West London and …
Merton — recommendation 2.2
Where it is likely that a family member will administer medication and monitor compliance an assessment should be prioritised and any gaps in understanding about the medication and its risks, resulting from language/educational differences, should be identified and responded to, to ensure that the individual is properly equipped and supported …
South London and Maudsley NHS Foundation …
South London and Maudsley …
Harrow — recommendation 15
Review Prescribing Guidelines so that they explicitly address pregnancy tests before each new episode of prescribing – including re-titrations.
Compass
Walsall — recommendation 8.7
The Black Country & Birmingham West CCG and The Black Country Healthcare Foundation Trust should agree a protocol to ensure that every child or adolescent prescribed ADHD medication is offered a consultant-led review of the need for continued medication into adulthood.
Black Country & Birmingham West ICB …
NHS Black Country ICB
Bristol — recommendation 2
Review the protocols for risk assessment and management, ensuring that (a) medicine compliance is considered for patients with a history of violence, (b) that post transition assessments are scheduled/conducted for this cohort, (c) fluctuations in patient insight are considered and (d) that this is explicitly documented in the handover between …
Avon and Wiltshire Mental Health Partnership …
Avon and Wiltshire NHS …
Norfolk — recommendation 7
GP Practices to ensure that they have a process in place when patients do not respond to requests to attend for a monitoring check, related to their medication – for example a blood test or blood pressure check.
Norfolk and Waveney Integrated Care Board
NHS Norfolk and Waveney …
Buckinghamshire — recommendation ORB-4
Keyworker to confirm any medication changes with the prescriber and to record these within the service user/ patients case notes and care plan. Keyworker and other ORB staff who have contact with the service user / patient to observe and monitor for any changes in mental health and to ask …
One Recovery Bucks (Midlands Partnership NHS …
Colchester — recommendation 4
NHS England and North East Essex Clinical Commissioning Group to further to raise awareness on the potential misuse of prescription drugs particularly Pregabalin and Gabapentin with GP practices and prescribers across Essex including circulation of the Public Health England guidance.
NHS England | North East Essex …
NHS England
Somerset — recommendation Recommendation 5.
That GPs follow up hospital attendance discharge notices with the hospital and or patient. Especially regarding those patients who have a known history of DVA, long term prescription of anti-depressant medication, substance misuse, or mental health issues.
Somerset Clinical Commissioning Group (GP) | …
NHS Somerset Clinical Commissioning …