MAR chart errors
Failures in accurately completing medication administration record (MAR) charts, indicating risks in medication management.
Source spread
Where this theme appears
This theme appears across 15 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
114 PFD reports
4 HSSIB recs
43 CQC actions
17 PPO recs
2 IOPC recs
12 IMB recs
11 IMB reports
2 patient safety alerts
1 Scottish FAI
1 Article 2 learning point
1 DHR rec
19 PHSO decisions
1 LGO/SPSO decision
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.
Prevention of Future Deaths reports(114)— showing 50 strongest matches
Jill Sinson
Concerns: The coroner noted insufficient regular monitoring by the GP and a Staff Nurse's assessment that lacked appropriate referral and review of medical records. Unsupervised monthly prescriptions of significant medication were also issued without due consideration of the deceased's self-harm history.
Overdue
Tripta Rani Kumar
Concerns: The patient's medical notes were altered, removing a documented penicillin allergy without signature or verification, which led to a penicillin-containing antibiotic being prescribed and posed a risk of anaphylactic shock.
Overdue
Judith Marshall
Concerns: The coroner noted concerns regarding the policing of internal pharmacy error records and the lack of mandatory read-back procedures or software to prevent dispensing mistakes. There is also no central database for monitoring prescription errors.
Response (General Pharmaceutical Council): • The General Pharmaceutical Council stated it would review its inspection approach to include further interrogation of recorded errors. • The General Pharmaceutical Council indicated it would highlight its guidance … (AI summary)
Response (NHS England): • NHS England stated it would emphasise the requirement for community pharmacies to report patient safety incidents to the National Reporting and Learning System (NRLS) within the 2014/15 contract. • … (AI summary)
Response (Royal Pharmaceutical Society): • The Royal Pharmaceutical Society stated it would raise awareness and encourage the use of 'read-back' in its guidance. • The Royal Pharmaceutical Society indicated it would raise awareness of … (AI summary)
Response (Department of Health): • The MHRA contacted the marketing authorisation holder for morphine sulphate MR capsules, who agreed to improve packaging, and the MHRA will issue an alert to pharmacists. • An integrated … (AI summary)
Responded
Kerry Jacobs
Concerns: The coroner noted a lack of documentation for steroid prescriptions outside usual guidelines and insufficient communication with the consultant. There was also no protocol for pharmacists to discuss queried dosages with clinicians.
Response (Surrey Sussex Healthcare NHS Trust): • A directive has been issued requiring staff to record the rationale for prescribing medication outside BNF guidelines and to document discussions with pharmacists regarding queried prescriptions. • The Chief … (AI summary)
Responded
Lee Hollman
Concerns: The coroner identified concerns regarding the maintenance of accurate and updated medical records, specifically relating to medication details. There was also a lack of an effective system for issuing repeat prescriptions and reviewing patients according to guidelines.
Response (Royal College of General Practitioners): • The Royal College of General Practitioners' (RCGP) GP Curriculum includes guidance on accurate medical record-keeping and information management. • The RCGP highlighted a 2011 joint statement with the Royal … (AI summary)
Response (Riverside Surgery): • The practice reviewed and rewrote its repeat prescribing policy, specifically for psychotropic medications. • The clinical IT system was updated to improve the recording of medication changes and to … (AI summary)
Responded
Jennifer Tompkins
Concerns: The coroner noted potential training issues regarding the correct administration speed of IV medications and a lack of routine documentation when IV infusions are stopped early.
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
Redmond Johnson
Concerns: The coroner identified gaps in gathering medical history, managing complex medications, documenting test results, and assessing detainees' fitness for transfer, including ensuring sufficient notice for these assessments prior to transfer to court.
Overdue
Ralph Goslin
Concerns: A junior doctor did not recognise a sub-therapeutic sodium valproate level due to an unclear reference range, which delayed the recognition that the patient was not taking their anti-epilepsy medication.
Response: • The Trust issued two Patient Safety Alerts concerning epilepsy care plan reviews and bathroom/shower room protocols. • The Trust commissioned specialist epilepsy training for all inpatient and residential services … (AI summary)
Responded
Beatrice Gatt
Concerns: An error in transferring medication details between Mars sheets led to Mrs Gatt not receiving her anti-psychotic medication, with the coroner noting a lack of formal training for nursing staff on these procedures.
Overdue
Philip Allen
Concerns: The coroner noted that specialist advice was not followed and a medication the patient had stopped was repeatedly prescribed. Concerns were raised about the system at Eltham Palace Surgery that allowed this to occur, and the lack of clarity on whether improvements have been made.
Response (Eltham Palace Surgery): • The practice conducts twice-weekly ward rounds at the Oaks Home and performs regular medication reviews every three months by a Prescribing Advisor and twice a year by the attending … (AI summary)
Responded
Colin Ireland
Concerns: The coroner noted an inadequate discharge summary that failed to clarify medication status and the risks of late Friday discharges without assured weekend healthcare provision. Gaps in medication administration and venous thromboembolism risk assessments were also identified.
Overdue
Lottie Reid
Concerns: The coroner noted a discrepancy between medication records following hospital discharge and a lack of a protocol to easily check such discrepancies, particularly on weekends.
Response (Birmingham Heartlands Hospitals): • The Trust is sending a clinical alert to all wards at Good Hope Hospital to reinforce the Intermediate Care Procedure. • The Trust is amending the nursing discharge checklist … (AI summary)
Responded
Thomas Farrell
Concerns: The care home did not obtain a complete record of prescription drugs from the resident's GP, resulting in some medications not being administered.
Overdue
Mary Bloom
Concerns: The coroner identified non-compliance with Trust policy for heparin administration, specifically regarding weighing the patient, consulting haematology for low weight, and re-attempting baseline bloods. Critical information for underweight patients on the heparin poster was also not sufficiently visible.
Response: • The Trust introduced three new policies and a new chart for the administration of unfractionated heparin. • The Trust's new guideline for heparin administration is weight-based, with APTTR checks … (AI summary)
Responded
Marie Quinn
Concerns: The coroner identified concerns regarding medication management at Richmond House Nursing Home, where excess medication was not queried. Inaccurate hospital discharge notes led to the premature cessation of prophylaxis treatment for a patient.
Overdue
Robin Brett
Concerns: Nursing staff did not identify a missed steroid dose, and there is no system, either paper or electronic, to alert medical staff about patients on long-term steroid treatment.
Overdue
Steven Rogers
Concerns: The coroner noted a patient was discharged as medically fit by a doctor who had not seen them, relying on nurse information and colleagues' assessments. Concerns were also raised about the erroneous omission of the patient's long-acting insulin during their hospital stay, which altered their medication regime.
Response (Steven Rogers): • The Trust has a risk assessment in place regarding paper charts and reminds staff to check for them. • A specialist "Task & Finish Group" is in place to … (AI summary)
Responded
Betty Addison
Concerns: The coroner raises concerns about insufficient control over medication administration and monitoring at Alexandra Court Care Home, noting that residents may receive incorrect amounts of prescribed medication.
Overdue
Hayley Clark
Concerns: The report notes that staff did not adjust the prescribed and administered paracetamol dosage for Ms Clark, despite her extremely low body weight.
Response (The Rotherham NHS Trust): • An additional action plan has been provided. • The Patient Safety Group will oversee the completion of the action plan. (AI summary)
Responded
Peter Rowe
Concerns: A penicillin-based antibiotic was prescribed and administered despite a GP referral letter stating a penicillin allergy. Concerns were raised about the deletion of allergy information from the patient's record and the insufficient verification of allergy status, particularly given the patient's cognitive impairment.
Overdue
Terence Stilges
Concerns: The coroner identified a practice of writing discharge summaries in advance, which led to a patient being discharged prematurely before all necessary test results, including a second troponin, were available.
Response (NHS England): • The Heart of England NHS Foundation Trust stated it had taken appropriate steps to prevent a re-occurrence of the issues. • The Trust stated it was reviewing electronic systems … (AI summary)
Overdue
Harold Goulding
Concerns: Communication broke down between the anti-coagulation clinic, the GP, and the care home regarding a resident's new GP details. Additionally, the General Practitioner did not consider the Medication Administration Record held by the home during new resident reviews, indicating a lack of a system for medication approval.
Response (Orchard Care Homes): • Meetings were held with nursing staff to discuss the incident and identify lessons. • Daily meetings were implemented, and a protocol document was created to improve communication with external … (AI summary)
Responded
Fred Whittaker
Concerns: The medical centre continued prescribing a drug in error after a request to stop it, because there was no mechanism to record the reasons for discontinuing medication in clinical records. This practice may be replicated in other GP practices.
Response (NHS England): • The practice and GPs involved have undertaken a review and implemented measures to prevent recurrence. • NHS England's Medical Director for Greater Manchester will write to all GPs and … (AI summary)
Overdue
Thomas Jordan
Concerns: The coroner identified that medication continued to be administered in prison despite hospital advice to discontinue it, owing to a communication breakdown between the hospital and prison, and discharge correspondence not being immediately available or reviewed by prison healthcare staff.
Response (Care UK): • Care UK's Head of Healthcare at HMP Leeds discussed the matter with the Clinical Director for Urgent Care at Leeds Teaching Hospital. • The Hospital's Clinical Director agreed that … (AI summary)
Overdue
Scott Hooper
Concerns: The coroner noted an incorrect weight recording, impacting anti-coagulant dosage, and a lack of clear documentation for clinical decisions. Further concerns were raised about the insufficient dissemination of lessons learned and the absence of a plan for weight estimation training.
Overdue
George Cheese
Concerns: A patient with suicidal thoughts was prescribed a large quantity of antidepressant medication, and there was no system to flag his notes to limit repeat prescriptions from the GP practice.
Response (Woodley Centre Surgery): • The surgery introduced a policy requiring repeat prescriptions and depression reviews to be conducted by GPs only. • An antidepressant prescribing policy was developed and circulated to all GPs … (AI summary)
Responded
Joyce Rumming
Concerns: The coroner identified gaps in communication between different software packages, leading to a patient's allergy marker being missed and an antibiotic administered despite a known allergy.
Response (Great Western Hospital NHS Trust): • The Trust developed and made available six factsheets on patient medication allergies for all staff. • The Trust plans to implement a new electronic clinical note system designed to … (AI summary)
Responded
Craig Hamilton
Concerns: The coroner identified a lack of clear procedures for managing and monitoring patients who seek to obtain more medication than prescribed, and for exploring alternative pain management during reviews. Concerns were also raised about systems for discussing dosage implications with patients and recording such discussions.
Response (Manor Field Surgery): • The surgery identified patients prescribed tramadol and other high-risk medications, changing electronic prescriptions to paper for doctor review. • It completed a thorough review of medication ordering and review … (AI summary)
Responded
Ahsiyah Bibi
Concerns: The coroner noted delays in identifying high potassium due to blood gas results being separated from records, and a drug error occurred with insulin prescribing for hyperkalaemia, for which there had been no Trust-wide review of the risks.
Overdue
Charlotte Agnew
Concerns: The coroner noted insufficient suicide risk assessment, no comprehensive care plan, and ineffective transfer of care prior to discharge from psychiatric services. Concerns also included delayed urgent assessments and medication recommendations without a psychiatrist's review.
Overdue
Songul Bozdag
Concerns: The coroner noted gaps in the care co-ordinator's mandatory reviews and record-keeping for Ms Bozdag, including unrecorded discussions and failure to update her drug card, resulting in under-medication.
Response (East London NHS Foundation Trust): • An Inbox-based system was implemented to communicate discharge care plans and monitor actions, including medication changes. • Monthly supervision for care coordinators was reinforced, with regular audits undertaken to … (AI summary)
Responded
Jennifer Midgley
Concerns: The drug administration chart does not clearly differentiate between oral and intravenous paracetamol, nor does it include a patient's weight reference for intravenous administration, which is needed to modify dosage.
Overdue
Claire Medhurst
Concerns: The discharge process did not include cautionary advice on analgesic use, and treating clinicians did not receive alerts from the haematology laboratory for abnormal ALT and toxic paracetamol levels.
Response (Medway NSH Trust): • The Trust stated that staff briefings and daily safety huddles have reinforced the importance of providing essential information on paracetamol overdose upon discharge. • A new flagging system was … (AI summary)
Responded
Ronald Brewer
Concerns: Concerns were raised regarding the administration of medications, with particular note on the documentation and dispensation of palliative medications.
Response (Barchester Healthcare): • A Deputy Manager with a palliative care background was appointed to support training and practice in end-of-life care. • Staff completed competency assessments and further training on medicine management, … (AI summary)
Responded
Stephen Coulson
Concerns: The coroner identified deficiencies in the system for controlled drug management. Concerns also included a lack of escalation in the observation policy for patients needing review before discharge, and a witness's non-acceptance of lessons from the investigation.
Response (NHS England): • The Trust has updated its Controlled Policy and Opiate Patch Monitoring Form to enhance documentation of opiate patches. • The Trust has undertaken and plans to deliver further education … (AI summary)
Response (CQC): • The CQC reviewed the Trust's controlled drugs policy and provided suggestions for improvements. • The CQC stated it would monitor the Trust's planned audit of the opioid patch monitoring … (AI summary)
Overdue
Hayley Sheehan
Concerns: The procedure for repeat prescription requests relies on administrators to identify early requests, as the surgery's software does not automatically flag them. More safeguards are needed to ensure these requests are identified and brought to a GP's attention.
Response (The Moat House Surgery): • The surgery sent an email to EMIS Health requesting changes to the prescribing process to flag early prescription requests. • The IT Manager developed a pop-up box within patient … (AI summary)
Responded
Paul Mullen
Concerns: The coroner raises concerns about the 'red flag system' for reporting uncollected methadone prescriptions, noting that reports were routed indirectly through GMMH instead of directly to the patient's Key Worker at Addaction, causing delays. This system did not allow for earlier reporting for diligent patients who missed a single dose.
Overdue
James Quinton
Concerns: Poor quality nursing notes and observation charts hindered consultants' understanding of patient events. The coroner also identified a lack of checking procedures for verbally prescribed medications, which led to an incorrect drug administration.
Response (Doncaster Bassetlaw Teaching Hospital): • The Emergency Department commenced training individuals as scribes to improve observation recording during resuscitation. • A working group was established to explore IV drug administration systems and processes in … (AI summary)
Responded
Michalla Sweeting
Concerns: The coroner highlighted that handovers for prisoners undergoing detoxification must include all patients and a registered nurse's review of records. Further concerns related to ensuring observations are taken closer to medication dispensing times to inform staff.
Overdue
Andrew Craig
Concerns: The coroner identified ongoing issues with the use of prescription and illicit drugs at HMP Guys Marsh, noting that the chaotic medication dispensing process at the healthcare hatch allows for drug transfer and redistribution among prisoners.
Response (HM Prison Probabtion Service): • A plan to upgrade cell windows to 'safer cell' standards has been approved and is provisionally scheduled for delivery in 2019/20. • A new local substance misuse policy has … (AI summary)
Response (Care UK): • Care UK confirmed it had implemented measures to reduce medication diversion, including reviewing prescribing practices and reducing the number of patients receiving supervised medication. • Care UK provided substance … (AI summary)
Overdue
Daphne Penn
Concerns: The coroner noted a more rapid steroid reduction rate was initiated than originally suggested, a delay in transmitting family concerns about the patient's condition to medical staff, and an additional decrease in steroid dose due to a prescribing error.
Overdue
Angela West
Concerns: The coroner noted that the patient's high-risk surgery was scheduled for a Thursday, meaning post-operative care occurred under weekend staffing. Concerns were also raised about the patient's location on a general surgical ward and a lack of fluid balance charts during dehydration.
Response (Barts NHS Trust): • Out-of-hours surgical cover has been enhanced to ensure daily review of acute inpatients seven days a week. • The junior doctor induction programme now includes a section on clinical … (AI summary)
Responded
Michael Drewell
Concerns: A senior clinician's advice on medication duration was not followed and was not transferred to electronic patient notes. This created a gap as junior doctors, who are not expected to consult handwritten records for prescribing, consequently missed critical information.
Response (Leeds Teaching Hospitals NHS Trust): • The Trust has written to Clinical Directors to remind all clinicians about the importance of robust handover and communication. • The Trust described existing good practice in other clinical … (AI summary)
Responded
Cuthbert Hingert
Concerns: The coroner identified several medication errors, including duplicate antiplatelet prescribing and an incorrect aspirin dosage, alongside a delay in documenting a prescribing decision. Concerns were also raised about insufficient clinician training in the medicines database and a nurse's failure to follow incident reporting protocol for errors.
Overdue
Gwyneth Edwards
Concerns: The coroner noted that staff recorded National Early Warning Scores (NEWS) but did not action them according to protocol, and a Mobile Medic request was marked complete without attendance. Concerns also included insufficient staffing impacting patient monitoring and record-keeping.
Overdue
Kalma Ram-Henman
Concerns: The coroner identified concerns regarding incomplete fluid charts, failure to administer prescribed potassium and intravenous fluids, and missed opportunities to monitor and recognise patient deterioration due to inadequate reading of notes during transfer.
Response (Brighton and Sussex University NHS Trust): • The Trust implemented a new SBAR telephone handover form and issued a Safety Alert regarding the correct use of drug prescription charts for infusions. • The Trust plans to … (AI summary)
Responded
Jacqueline Elliott
Concerns: The GP practice's computer system incorrectly classified repeat prescriptions, hindering medication reviews, and clinical notes lacked sufficient detail. A lack of continuity of care led to repeated painkiller prescriptions without exploring alternative treatments, and a large tramadol prescription was issued without clear rationale.
Response (Trafford CCG and Department of Health and Social Care): • The CCG stated it would raise awareness among GPs and pharmacists regarding the review of acute and repeat medications, with related safeguarding training having commenced in March 2019. • … (AI summary)
Responded
John Thorp
Concerns: The coroner noted inconsistent prescribing practices for TED stockings by medical staff across different hospital areas, which could lead to them not being administered and increase the risk of thromboembolic formation.
Response (London North West University Healthcare NHS Trust): • The Trust formulated a new, standardised prescription chart for TED stockings, which includes a section for prescribing and daily nursing documentation. • Information on the new process was disseminated … (AI summary)
Responded
Malcolm Rathmell
Concerns: An incorrect warfarin prescription, resulting from a mislabelled anti-coagulation chart, went unidentified by multiple medical professionals for several days and lacked ward-based pharmacy review. The Trust's proposed actions to address such prescribing errors are still in early stages of implementation.
Overdue
HSSIB safety recommendations(4)
Medication not given: administration of time critical medication in the emergency department
When the medication was prescribed, the morning dose was incorrect.
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
How does your organisation capture information when patients self-administer time critical medications?
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
A dose was prescribed but not given on day 3.
Learning Prompt
The use of an appropriate flush fluid with arterial lines
It may be beneficial to review the unintended consequences associated with the use of pre-populated prescriptions for arterial flush fluid and also insulin.
Safety Observation
CQC inspection actions(43)
Russells Hall Hospital
The trust should ensure that medicines charts are completed correctly.
Should Do
Queen's Medical Centre
The trust should ensure that weights are recorded on medicines charts.
Should Do
Nottingham City Hospital
The trust should ensure that weights are recorded on medicines charts.
Should Do
Mount Vernon Cancer Centre
The trust must ensure that there are systems and processes operating effectively to safely store, prescribe, administer and record medicines across all core services.
Must Do
Kidderminster Hospital and Treatment Centre
Ensure medicine charts are audited to include missed doses.
Should Do
Derriford Hospital
The service must ensure adequate standards of documentation is maintained, including but not limited to: CTG monitoring, patient observations, medicine charts and handover of care. The service must ensure that patient records are stored securely at all times.
Must Do
Cumberland Infirmary
The trust must ensure the timely administration and accurate recording of all medications, including oxygen, prescribed to patients under its care. Regulation (1)(2)(c)(g).
Must Do
Broomfield Hospital
The trust should ensure prescription charts are completed with women’s weight and allergy status.
Should Do
Royal Sussex County Hospital
The trust should ensure staff record why medications are not administered.
Should Do
Poole Hospital
Ensure staff recognise medicine errors and include omitted doses. All medicine errors must be recognised, reported, investigated, monitored and discussed fully.
Must Do
Musgrove Park Hospital
They should consider how ‘medicines as required’ (PRN) medicines and patient weight is recorded on the electronic medicines record.
Should Do
Newham University Hospital
The services should ensure all drug charts checked by the pharmacist team are clearly documented and audited.
Should Do
Aspirations (Northampton)
The recording of administration of medicines required improvement. Medicine administration records [MAR] had not been consistently signed or transcribed in line with best practice.
Should Do
Tregertha Court Care Home
The provider must ensure that accurate, complete, and contemporaneous records are kept in respect of each service user, specifically regarding the administration of medicines, to confirm that people receive their medicines as prescribed.
Must Do
Westmorland General Hospital
The trust must ensure that controlled drugs are safely prescribed, administered, recorded and stored and that registers are correctly and fully completed. The trust must ensure there is a system in place to assess and monitor formal competencies for nursing …
Must Do
West Cumberland Hospital
The trust must ensure the timely administration and accurate recording of all medications, including oxygen, prescribed to patients under its care.Regulation(1)(2)(c)(g).
Must Do
Cumberland Infirmary
The trust must ensure the timely administration and accurate recording of all medications, including oxygen, prescribed to patients under its care. Regulation (1)(2)(c)(g).
Must Do
St Benedict's Hospice
The service MUST ensure all staff are aware of and consistently follow the trust policy to safely prescribe, administer, record and store and dispose of medicines.
Must Do
Victoria Infirmary
The service should continue to maintain complete records of photographic identification in children’s medication charts used in special schools.
Should Do
Kingsleigh Residential
We recommend the provider ensures current guidance is followed for handwritten MARs and as required protocols.
Should Do
Canterbury House Care Home
The recording of the stock available and administration in a register is a legal requirement. This register was not accurate as both staff had not always signed to confirm administration.
Should Do
Bellevue Healthcare Limited
The provider must ensure accurate and clear management of medicines, including insulin and topical creams, with complete and consistent records.
Must Do
Royal Hallamshire Hospital
The trust must ensure that medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe.
Must Do
Royal Hallamshire Hospital
The trust must ensure that medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe.
Must Do
Fleetwood Hospital
The trust should ensure staff comply with guidance around medicines reconciliation and administering of paracetamol in the four-hour window.
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
Cumberland Infirmary
The trust must ensure that controlled drugs and other medications should be stored and recorded correctly and securely. Regulation 12(1)(2)(g).
Must Do
Durham Diagnostics and Treatment Centre
The service MUST ensure all staff are aware of and consistently follow the trust policy to safely prescribe, administer, record and store and dispose of medicines.
Must Do
Advance Home Help and Support Services
We highlighted this to the registered manager and requested that they look at current guidance available about the recording of medicines to ensure that they were appropriately recording the administration of medicines.
Should Do
Goldenley Care Home
Further focus was required in terms of medicines to be taken "as required".
Should Do
Benthorn Lodge
The registered person had not protected people against the risk of unsafe management of medicines. The systems in place to ensure medicines were administered safely were not consistently followed.
Must Do
The Everley Residential Care Home
We recommend that people’s MAR charts are signed by staff after the medication has been witnessed as being taken.
Must Do
Royalcare- Thanet
The registered manager took immediate action to remind staff body maps needed to be completed to show where pain patches had been placed.
Should Do
Ranyard at Mulberry House
The provider should note for medicines administered as skin patches there was no record of the applicationsite, so it was unclear whether a different area of skin was used each time the patch was changed to avoid damage to the …
Should Do
M N Pulse Solutions
improvement was needed to include information about their medicines within their care plan.
Must Do
Care Outlook (Bellerophon House)
Staff reported there was some inconsistency in the electronic records of medicines tasks, for example some people's care call listed each medicine staff needed to administer and others recorded a task of administering medicines prescribed without listing them.
Should Do
St.Theresa's Nursing Home
The provider must ensure that medicines are supplied, stored, administered and disposed of safely and in accordance with the law, including accurate record-keeping for handwritten entries, cream applications, stock levels, and appropriate storage temperatures for cold-chain medicines.
Must Do
Ashbourne House - Torquay
People's medicines were not always stored safely. People did not always have accurate records and information in place relating to their medicines. Monitoring systems were not effective.
Must Do
Westwood Residential Care Home
We recommend the provider reviews systems for storing medication and improves records relating to 'when required' medicines.
Should Do
The Warren Residential Lodge
the information relating to the effectiveness of these medicines was not always clearly documented in the MAR; although this information was available in care records. The deputy manager told us they would ensure staff added this information to the MAR …
Should Do
Spencer House
Staff monitored the temperature of the medicine's rooms. However, there had been occasions when staff had not recorded the temperature. This was an area for improvement.
Should Do
Lady Ida Lodge
One person was missing a body map for staff to record where a pain patch had been applied.
Should Do
Beech Close
To promote good practice guidance, the implementation of a body chart should be considered too clearly record the areas where prescribed topical medication needs to be applied.
Should Do
PPO death in custody recommendations(17)
The Head of Healthcare
The Head of Healthcare should ensure that when a prisoner does not receive their medication, healthcare staff record the reason on the prisoner’s medications history sheet.
Manx Care
Manx Care should implement electronic medication administration records.
The Head of Healthcare at Parc
The Head of Healthcare at Parc should ensure that the prison pharmacist ensures there are adequate supplies of lancets and blood testing strips for all prisoners who use insulin.
The Head of Healthcare at Parc
The Head of Healthcare at Parc should ensure that the prison pharmacist regularly reviews the medication needs of prisoners who use insulin and that insulin prescriptions are ordered promptly;
The Head of Healthcare
The Head of Healthcare should ensure that when a prisoner reports an overdose of prescribed medication, healthcare staff follow a recognised process to urgently establish what medications, and how much, might have been taken.
The Head of Healthcare
The Head of Healthcare should ensure that there are timely reviews when a patient refuses to take their medication.
The Head of Healthcare at HMP Liverpool
The Head of Healthcare at HMP Liverpool should ensure that regular medication in possession risk assessments (MIPRA) are undertaken when there are changes in patient’s circumstances or there are concerns regarding the compliance and adherence of medications, in accordance with …
The Head of Healthcare
The Head of Healthcare should ensure that prescribers consider the full list of a new prisoner’s medications and record their reasons for any they do not continue.
The Head of Healthcare of HMP Liverpool
The Head of Healthcare will want to ensure all healthcare staff ensure continuity of prescribing of all significant and/or critical medicines, after arrival in prison without delay and additionally that doses are not missed due to delays in repeat prescriptions.
The Head of Healthcare and the Forward Trust Service Manager
The Head of Healthcare and the Forward Trust Service Manager should ensure that there is a care plan in place for patients who require clinical observations immediately before receiving their medication; the results of observations are documented; and adjustments to …
The Head of Healthcare at HMP Haverigg
all prescribers are aware of Spectrum Community Health CIC’s medicines in possession policy in relation to propranolol.
The Head of Healthcare at HMP Haverigg
information relating to incidents of self-harm by overdose reported as part of the medicines in-possession risk assessment should be checked against the medical records to ensure accuracy;
The Head of Healthcare
The Head of Healthcare should ensure that there is a robust blood test monitoring system in place so that samples that are lost, insufficient or mislabelled are reviewed and, if necessary, repeated.
The Head of Healthcare
The Head of Healthcare should ensure that medication reconciliations are made in accordance with the community prescriber of that medication and where this is the community mental health team, they must confirm they are prescribing that medication and support this …
The Head of Healthcare
The Head of Healthcare should ensure that when new prisoners arrive at Eastwood Park with complex medication and health issues, a prescriber (or equivalent registered professional) has an early face-to-face conversation with the patient about their medication.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff: review prisoners’ starting antidepressants in line with Royal College of General Practitioners’ guidance; record actions and decisions about a prisoner’s ongoing care in their medical record and check that the entries …
The Head of Healthcare
The Head of Healthcare should ensure that when staff dispense over the counter (non-prescribed) medication, they record the reason in patients’ medical records.
IOPC learning recommendations(2)
Recommendation - Suffolk Constabulary, May 2022
The IOPC recommends that Suffolk Constabulary review their custody booking-in procedure to ensure that when two or more detainees are brought into custody with named (boxed) medication, these are separated, booked-in with each respective detainee and recorded on the Custody …
Complaints raised in relation to detention in custody – Essex Police, June …
The IOPC recommends that Essex Police should amend their policy to ensure that where a Health Care Professional (HCP) decides not to administer a medication that they have been informed a detainee has been prescribed, the HCP should record this …
IMB annual reports(11)
Heathrow Short Term Holding Facility (2020)
This IMB report for Short Term Holding Facilities at London Heathrow, London City Airports, and Becket and Eaton House Reporting Centres (Feb 2019-Jan 2020) highlights concerns about the suitability of accommodation for longer stays and children, and overcrowding due to transport delays. Key issues include detainee access to medication and legal advice, the quality of DCO inductions and engagement, and challenges in Board monitoring of removals. While positive developments were noted in some areas, several critical recommendations from previous years remain unaddressed.
PRISON
Key concerns
Oakwood (2020)
HMP Oakwood maintains good overall safety and humane treatment, with commendations for staff collaboration, peer-led initiatives, and positive reception processes. However, significant concerns persist regarding the quality and quantity of education provision by Novus due to staffing issues, and a lack of national progress on prisoner property transfers. Other key issues include inconsistent use of force implementation, deteriorating cell facilities, and challenges in healthcare provision such as medication transfers and secondary care capacity. The Board will continue to monitor these areas in the next reporting period.
PRISON
Key concerns
North and Midlands STHF (2020)
The North & Midlands STHF IMB report for 2020 highlights the impact of the COVID-19 pandemic on its monitoring activities, leading to remote oversight. The Board notes humane treatment by DCOs and the introduction of translation devices. Key concerns include the increasing length of detentions in reporting centre holding rooms which are unsuitable for long stays, the persistent issue of detainees lacking access to prescribed medication, and bureaucratic hurdles for IMB members to access airside facilities.
PRISON
Key concerns
North West and Midlands STHF (2023)
The Board has resumed actual visits to most locations, with two exceptions, and consists of three active members who continue their duties robustly, despite being under-strength. Key concerns include the persistent issue of detainees being denied access to prescribed medication in facilities without full-time medical professionals, and the slow rectification of structural and equipment deficiencies. Positive developments include the resolution of airside pass issuance and observations of humane and professional treatment of detainees.
PRISON
Key concerns
North East Midlands, Yorkshire & Humber STHF (2023)
This is the first annual report for the North East Midlands, Yorkshire & Humberside IMB, covering Short-Term Holding Facilities (STHFs) from February 2022 to January 2023. While staff conduct and detainee treatment generally received positive feedback, significant concerns arose regarding the unsafe opening and managing large intakes at Swinderby Residential STHF. The Board also highlighted the critical and unresolved issue of Home Office policy preventing detainees in all STHFs from taking prescribed medication, deeming it inhumane and dangerous.
PRISON
Key concerns
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)
The Scotland and Northern Ireland STHF IMB report highlights generally humane treatment by staff but identifies significant concerns across multiple facilities for the period February 2022 to January 2023. Key issues include the unsafe removal of prescription medication, inadequate disability provisions, and the unsuitability of airport holding rooms for increasingly prolonged detentions. The Board also notes long-overdue building alterations at Larne House and ventilation issues across the estate, urging urgent action from the Home Office and facility managers.
PRISON
Key concerns
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
This report highlights significant shortcomings in the Short-term Holding Facilities (STHFs) in Scotland and Northern Ireland. Key issues include a failure to separate men and women at Larne House, inadequate accommodation, and inconsistent healthcare provision often leading to the removal of essential medication. Detainees frequently face unnecessarily long stays due to systemic inefficiencies, coupled with a lack of transparency and accessibility challenges across the estate.
PRISON
Key concerns
North and Midlands Short Term Holding Facilities (2022)
This IMB annual report for North & Midlands Short-Term Holding Facilities highlights ongoing concerns regarding healthcare provision, particularly the lack of access to prescribed medication and the absence of full-time medical professionals in most facilities. The Board's ability to monitor airside holding rooms remains compromised by issues with airport passes. Despite these challenges, the Board observed humane and dignified treatment of detainees by staff.
PRISON
Key concerns
London Heathrow and City Airports (2022)
This IMB report for Heathrow and City Airports' Short-Term Holding Facilities covers February 2021 to January 2022. It highlights ongoing concerns regarding extended detention times, inadequate facilities—especially for families in Terminal 5—and a critical lack of Wi-Fi and consistent access to medication across all sites. Despite these issues, the Board notes positive developments such as improved access to medical support at Heathrow, updated religious provisions, and generally respectful interactions from staff, while urging further improvements in staffing, infrastructure, and detainee welfare.
PRISON
Key concerns
Scotland and Northern Ireland Short-Term Holding Facilities (2022)
This IMB annual report for Scotland and Northern Ireland's Short-Term Holding Facilities (STHFs) highlights significant welfare concerns for the reporting year ending January 2022. Key issues include widespread disability access shortfalls across the estate, an unacceptable increase in extended detentions in unsuitable airport holding rooms, and the unresolved problem of managing detainees' prescription medication. The Board also notes long-overdue facility upgrades at Larne House and inadequate ventilation systems, particularly concerning Covid-19 risks.
PRISON
Key concerns
Whatton (2025)
HMP Whatton, a Category C prison for sexual offenders, maintained an average population of 836. The IMB praised the safe environment, positive staff-prisoner relationships, and improvements in education and family contact. Key concerns include the persistent challenges faced by IPP prisoners, critical under-resourcing impacting the estate and services, and delays in transfers to Category D prisons. Outdated healthcare facilities and accessibility issues for prisoners with mobility problems also remain significant areas for development.
PRISON
Key concerns
IMB individual recommendations(12)
Stafford (2022)
Sustained effective healthcare and medicines management that delivers for the residents of HMP Stafford and not just PPG targets
HMPPS
Styal (2023)
The timely administration of medicines and the inadequate dispensing facilities remain a significant concern – how will this be addressed in the future?
Governor / Director
Erlestoke (2025)
What plans are being considered to ensure that prisoners arriving at HMP Erlestoke will have access to their essential medicines without a period of delay?
NHS / Healthcare Provider
In Progress
Elmley (2020)
The Board seeks reassurance that the healthcare department’s attempts at auditing the issue of paracetamol by prison staff on the wings is supported by managers. Given the near-miss this year, it is important that paracetamol is controlled in similar ways to any other medication provided in the prison.
Governor / Director
Durham (2020)
Why are incidents of prisoners missing three consecutive days of medication no longer reported?
Governor / Director
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.
Governor / Director
Wandsworth (2023)
Non delivery of medications has been a major concern to the Board this year. What is being done to ensure that this improves?
Governor / Director
Featherstone (2023)
Issues with low numbers of healthcare staff have, on occasion, meant that the regime has been disrupted because of delays dispensing medication. This has been an ongoing issue and consideration should be given as to whether the system can be changed to increase its reliability and consistency.
Governor / Director
Hollesley Bay (2024)
A review of the arrangements for dispensing medication is requested. The current regime is slow and cumbersome, which leads to frustration among prisoners and friction with healthcare staff.
Governor / Director
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. The Board …
Home Office
Five Wells (2025)
How can the healthcare unit improve prisoner understanding of changes to their medication?
Governor / Director
Five Wells (2025)
How can the healthcare unit improve prisoner understanding of changes to their medication?
Governor / Director
National patient safety alerts(2)
Health investigations(3)
An independent investigation into the care and treatment of Harry … — Rec 7
We recommend that LTHT take steps to ensure that the record-keeping in relation to medication prescription and administration is of the required standard. We suggest that this is included in their clinical audit programme.
Leeds and York Partnership NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of Harry … — Rec 14
We recommend that LTHT ensure that the pharmacy service routinely carry out checks on prescription sheets to identify if patients have had repeated missed doses of the same drug. Where there are repeated missed doses, we recommend that LTHT ensure that pharmacy staff escalate these cases to the consultant and …
Leeds and York Partnership NHS Foundation Trust
north_east_yorkshire
A Joint Domestic Homicide Review and independent mental health homicide … — Rec 9
The Trust must provide assurance that there is a system in place that ensures all patients receive depot medication as prescribed, and that records are made both in the medication chart and the electronic clinical record.
north_east_yorkshire
Article 2 learning points(1)
PHSO casework decisions(19)
P-002628 — Bradford Teaching Hospitals NHS Foundation Trust
Mr I complained the Trust missed opportunities to administer his father's regular medication, contributing to his death, and handled the internal investigation poorly.
NHS in England
Partly Upheld
May 2024
P-003516 — Barnsley Hospital NHS Foundation Trust
Mr L complained his wife received inappropriate antibiotics causing an allergic reaction, was not promptly transferred to a specialist unit, deteriorated without response, and had a wrong allergy recorded.
NHS in England
Apr 2025
P-004507 — Northern Care Alliance NHS Foundation Trust
Ms D complained the Trust prescribed contraindicated medication, poorly managed her father's bowel disease, and did not appropriately treat pulmonary embolism, contributing to his death.
NHS in England
Upheld
Oct 2025
P-004204 — University Hospitals Birmingham NHS Foundation Trust
Mr H complained about incorrect medication instructions, delayed scans/treatment, incorrect prescriptions, lack of mobility assistance, poor communication, and a long complaint response, worsening his condition.
NHS in England
Upheld
Oct 2025
P-001499 — United Lincolnshire Hospitals NHS Trust
Mr E complained the Trust did not properly manage his late wife's nutritional requirements or administer her regular medicines, questioning if better care could have prolonged her life.
NHS in England
Aug 2022
P-001693 — Northampton General Hospital NHS Trust
Mr O complained about the incorrect removal of an NG tube, failure to record an assault, not noting his macular degeneration, and not providing a lactose intolerance wristband during his inpatient stay.
NHS in England
Nov 2022
P-001929 — Lewisham and Greenwich NHS Trust
Ms T complained about a nurse's response to her mother's seizure, medication management, and delays in diagnosing meningoencephalitis, alongside poor complaint handling by the Trust.
NHS in England
Partly Upheld
Apr 2023
P-001976 — University Hospitals Birmingham NHS Foundation Trust
Mrs N complained about the Trust's medication management for Ms A (too much glucose, missed meds, failed blood thinning), a DNACPR order without consent, poor sepsis management, and conflicting communication.
NHS in England
Apr 2023
P-002630 — A practice in the Sheffield area
Mrs L complained the Practice wrongly deemed her husband lacked capacity, failed to remove a DNACPR, mismanaged medication and records, and provided an inadequate home visit leading to his death.
NHS in England
May 2024
P-003448 — East Sussex Healthcare NHS Trust
Miss B and Mrs B complained a nurse administered wrong medication, and the Trust delayed notifying the family of Mr B's deterioration, causing distress and affecting their grieving process.
NHS in England
Partly Upheld
Mar 2025
P-004147 — Lancashire Teaching Hospitals NHS Foundation Trust
Miss U complained about delayed stroke treatment, inconsistent information, early induced coma exit, and conflicting accounts, believing these contributed to her father's death.
NHS in England
Oct 2025
P-004423 — A practice in the City of Brighton and …
Mr M complained a GP practice did not adequately communicate changes in his medication, causing him distress.
NHS in England
Dec 2025
P-003865 — Portsmouth Primary Care Alliance Ltd
Miss G complained the Practice and PPCA failed to correctly test for and treat her grandfather's urinary tract infection, leading to his death.
NHS in England
Jul 2023
P-002349 — A practice in the Hertfordshire area
Mrs A complained the doctor missed stroke symptoms, failed to check blood pressure, and delayed/incorrectly managed her medication and blister packs.
NHS in England
Nov 2023
P-002299 — An practice in the Northumberland area
Mr W complained the Practice mishandled his diazepam prescription and incorrectly prescribed prednisolone, causing him stress, anxiety, and health issues.
NHS in England
Partly Upheld
Nov 2023
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-003604 — Frimley Health NHS Foundation Trust
Mrs J complained the Trust mishandled her mother's antibiotics and failed to correctly administer Parkinson's medication, significantly impacting her mother's mobility and recovery.
NHS in England
Jun 2025
P-001984 — The Princess Alexandra Hospital NHS Trust
Mr L complained about limited hospital visits, poor communication, delayed oral thrush diagnosis, inappropriate medication, and inadequate nursing care, including pressure sore prevention, leading to severe deterioration.
NHS in England
May 2023
P-002697 — East Lancashire Hospitals NHS Trust
Miss N complained about poor care for her father, including an uncommunicated DNACPR decision, delayed investigations/treatment, medication errors, and inadequate nutrition.
NHS in England
Partly Upheld
Jun 2024