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 12 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
114 PFD reports
20 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
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 GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, and staff neglected to review critical records or consultant advice.
Overdue
Tripta Rani Kumar
Concerns: A patient with a documented penicillin allergy was prescribed penicillin-containing medication after a critical allergy note was incorrectly overwritten without authorisation, creating a serious risk of anaphylaxis.
Overdue
Judith Marshall
Concerns: The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory read-back procedures, and a central error database.
Response (General Pharmaceutical Council): The General Pharmaceutical Council acknowledges the concerns and states they are considering publishing an anonymised summary of the case in their newsletter 'Regulate'. It highlights existing guidance and standards, including …
Response (NHS England): NHS England describes actions underway to improve medication safety, including publishing a new Patient Safety Alert on medication errors in March 2014. It also mentions a review of community pharmacy …
Response (Royal Pharmaceutical Society): The Royal Pharmaceutical Society acknowledges the concerns and says it could raise awareness and encourage use of 'read-back' as one technique amongst others to reduce errors in the guidance that …
Response (Department of Health): The Department of Health describes actions taken to address concerns around dispensing errors, including the MHRA working with NHS England to simplify medication error reporting. An integrated reporting route has …
Responded
Kerry Jacobs
Concerns: The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was also no protocol for pharmacists and clinicians to discuss queried medication dosages.
Response (Surrey Sussex Healthcare NHS Trust): The Chief Medical Officer issued a directive for staff to record the rationale for prescribing medication outside of BNF guidance, and the Chief Pharmacist has reiterated the medication screening procedure …
Responded
Lee Hollman
Concerns: The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.
Response (Royal College of General Practitioners): The RCGP and Royal Pharmaceutical Society will convene a multi-stakeholder group and establish a joint working group, including patients, to explore recommendations and develop a work program focused on shared …
Response (Riverside Surgery): Riverside Surgery met with the Horsham Community Mental Health Team to improve communication, discussed prescribing with the CCG, and has ongoing reviews for mental health patients, including specialist consultations, case …
Responded
Jennifer Tompkins
Concerns: The coroner expressed concern about potential training issues related to the administration of IV medications, and that the stopping of IV vancomycin infusions early may not be routinely documented, raising risks in other cases.
Overdue
Bridget Cahill
Concerns: The coroner questions how a patient prescribed morphine can overdose despite receiving less than the prescribed amount, suggesting attention be given to the maximum recommended dose and factors influencing morphine buildup in the body.
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA reviewed the post-mortem report and the pharmacokinetics/dynamics of morphine, concluding that the case does not prompt a review of the maximum permitted dose or a need to adjust …
Responded
Redmond Johnson
Concerns: Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing fitness for transfer, risking inadequate care for those with complex needs.
Overdue
Ralph Goslin
Concerns: An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, delaying the recognition of missed medication.
Response: The trust has commissioned specialist epilepsy training from the National Neurological Commissioning Support Unit, working with the National Epilepsy Society, across inpatient and residential services. The process for sharing recommendations …
Responded
Beatrice Gatt
Concerns: A critical antipsychotic medication was not administered due to a transfer error between medication sheets, highlighting a lack of formal training for nursing staff on medication management.
Overdue
Philip Allen
Concerns: The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist advised stopping it, indicating a risk of medication errors.
Response (Eltham Palace Surgery): The practice conducts twice-weekly ward rounds and medication reviews every 3 months by a prescribing advisor and twice a year by the attending clinician, using electronic prescriptions. They have repeatedly …
Responded
Colin Ireland
Concerns: Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to communicate essential treatment plans to prison healthcare, compounded by a risky late Friday discharge.
Overdue
Lottie Reid
Concerns: There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for checking these errors, especially problematic on weekends.
Response (Birmingham Heartlands Hospitals): Birmingham Heartlands Hospital is piloting new documentation within palliative care for clarity of prescribing. Dissemination of information about the Intermediate Care Procedure to all wards at Good Hope Hospital and …
Responded
Thomas Farrell
Concerns: The care home failed to obtain a full prescription history from the GP, resulting in critical medications not being administered and creating a clear risk of harm to residents.
Overdue
Mary Bloom
Concerns: Trust policy on heparin administration was not followed, including failure to weigh the patient, consult haematology, or take post-hydration bloods. Critical dosage advice for underweight patients was also easily missed due to poor visibility on posters.
Response: The trust implemented three new policies and a chart for unfractionated heparin administration. The guidelines now state that if the APTTR at 6hrs is outside the expected range then the …
Responded
Marie Quinn
Concerns: Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early cessation, and the nursing home failed to query excess medication.
Overdue
Robin Brett
Concerns: A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic drug charts for patients on long-term steroid therapy.
Overdue
Steven Rogers
Concerns: A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and staff erroneously omitted long-acting insulin during the patient's hospital stay.
Response (Steven Rogers): The Trust is moving towards a Trust-wide electronic patient record (EPR) which should resolve issues around paper charts. In the meantime, a specialist "Task & Finish Group" is in place …
Responded
Betty Addison
Concerns: A patient at a care home received five additional, unprescribed Dalteparin injections, with no clear explanation for their source or why they were administered.
Overdue
Hayley Clark
Concerns: Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack of appropriate medication management.
Response (The Rotherham NHS Trust): An action plan is in place to ensure correct management of oral paracetamol for adult patients of extremely low body weight, including updating the drug chart, developing information for staff, …
Responded
Peter Rowe
Concerns: A patient with severe memory loss was prescribed penicillin despite a documented allergy, which was later deleted. Allergy information was accepted uncritically from the patient and an uninformed spouse.
Overdue
Terence Stilges
Concerns: Repeated incorrect labelling of troponin blood samples resulted in unavailable critical diagnostic information, contributing to delayed diagnosis and patient discharge before subsequent readmission with an acute myocardial infarction.
Response (NHS England): NHS England supports the Heart of England NHS Foundation Trust's actions to review electronic systems, ensure junior doctors are aware of the discharge process through training, have individual clinicians review …
Overdue
Harold Goulding
Concerns: Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked systems to inform agencies of new GPs and ensure GPs review medication records.
Response (Orchard Care Homes): The care home created a handover document for sharing new resident information with GPs, and implemented protocols to ensure nurses accompany GPs on rounds to discuss medication charts and care …
Responded
Fred Whittaker
Concerns: A patient was erroneously re-prescribed medication due to the lack of a system for recording reasons for stopping drugs and poor prescription management, a risk potentially widespread in GP practices.
Response (NHS England): NHS England has been assured that the practice involved undertook a review and will do a significant event analysis. NHS England will share learning and best practice with GPs and …
Overdue
Thomas Jordan
Concerns: Communication breakdown and failure to review discharge correspondence at the prison led to continued, incorrect drug administration after hospital clinicians requested discontinuation. Electronic discharge summaries could prevent such errors.
Response (Care UK): Leeds Teaching Hospital has agreed to issue an electronic summary with all patients who transfer back to HMP Leeds following discharge. IT personnel from both the Hospital and Care UK …
Overdue
Scott Hooper
Concerns: Incorrect patient weight recording led to inaccurate anticoagulant dosage, and critical clinical decisions were unrecorded. Lessons from internal meetings were not effectively disseminated or applied to all high-risk patients.
Overdue
George Cheese
Concerns: A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system or "flag" in their notes to limit repeat prescriptions in such circumstances.
Response (Woodley Centre Surgery): The surgery introduced a policy requiring GPs only to issue repeat prescriptions and conduct depression reviews. They will also discuss the role of clinicians at a clinical meeting and arranged …
Responded
Joyce Rumming
Concerns: Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being administered a drug they were allergic to.
Response (Great Western Hospital NHS Trust): The trust is working to improve the handover process with ambulance services, including plans for a new clinical note system including patient allergies. They are also exploring the IT infrastructure …
Responded
Craig Hamilton
Concerns: A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss alternative pain management, poses significant risks.
Response (Manor Field Surgery): The practice identified patients prescribed tramadol and other medicines with the potential for self-harm and changed all electronic prescriptions to paper format for review. They have changed their policy for …
Responded
Ahsiyah Bibi
Concerns: Critical blood gas results were lost, delaying treatment. A significant insulin prescribing error occurred due to clinicians confusing doses, exacerbated by inadequate dose checking and lack of Trust-wide learning from errors.
Overdue
Charlotte Agnew
Concerns: The report describes failures in the transfer of care, suicide risk assessment, care planning, medication management, and response to a request for urgent assessment; the coroner remains concerned that these failings could recur.
Overdue
Songul Bozdag
Concerns: The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to under-medication, with no systemic safety net.
Response (East London NHS Foundation Trust): The Trust has implemented an inbox-based system to communicate discharge care plans to CMHT staff, and monthly supervision for care coordinators is now working in line with Trust procedures. Regular …
Responded
Jennifer Midgley
Concerns: The drug administration chart fails to clearly distinguish between oral and intravenous paracetamol, lacks patient weight reference for IV dosage, and omits a reminder for weight-modified administration.
Overdue
Claire Medhurst
Concerns: The discharge process lacked crucial cautionary advice on medication use, and treating clinicians failed to receive alerts for abnormal liver function and toxic paracetamol levels.
Response (Medway NSH Trust): The Trust will provide feedback to relevant staff regarding cautionary advice on analgesics and has discussed this in Emergency Department safety huddles. An algorithm has been written to add a …
Responded
Ronald Brewer
Concerns: Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.
Response (Barchester Healthcare): A Deputy Manager with palliative care experience was appointed to support training and practice, staff undertook competency assessments, further training was provided, medication fridges were replaced, and policies/procedures were updated. …
Responded
Stephen Coulson
Concerns: Inadequate systems for controlled drug management and patient observation policies, coupled with a failure to learn from investigations, posed risks to patient safety.
Response (NHS England): The Trust has updated its Controlled Drug Policy, updated the Opiate Patch Monitoring Form, amended nursing admission documentation, developed education around delirium and neurological assessment, implemented a new electronic neurological …
Response (CQC): CQC obtained and reviewed the Trust's revised action plan and will monitor its implementation during quarterly engagement meetings and future inspections. They also considered whether further regulatory action was needed …
Overdue
Hayley Sheehan
Concerns: The repeat prescription procedure is unsafe as it relies on manual flagging of early requests, with software unable to automatically identify them. More safeguards are needed, including software adaptation.
Response (The Moat House Surgery): The Moat House Surgery requested changes to the EMIS prescribing process to flag early prescription requests and developed a pop-up box alerting staff to prescriptions issued less than 30 days …
Responded
Paul Mullen
Concerns: The "red flag system" for reporting uncollected methadone prescriptions is ineffective; reports don't reach key workers directly, delaying intervention. Lack of shared systems between partner organisations further hinders communication.
Response: This response is not classifiable as it consists of nonsensical characters and cannot be understood.
Overdue
James Quinton
Concerns: Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a verbal prescription, highlighting a lack of essential checking procedures.
Response (Doncaster Bassetlaw Teaching Hospital): Doncaster and Bassetlaw Teaching Hospitals are training individuals as scribes, obtaining a software update for monitors, and have set up a working group with ED and Anaesthetics to explore the …
Responded
Michalla Sweeting
Concerns: Concerns were raised about inadequate handover procedures for detox patients, including nurses' record review responsibilities and the timing of observations relative to medication administration.
Overdue
Andrew Craig
Concerns: Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an ongoing drug problem despite previous warnings.
Response (HM Prison Probabtion Service): The plan to upgrade the cell windows has now been approved and is provisionally on Ministry of Justice programme for delivery in 2019/20. Additionally, a number of measures to reduce …
Response (Care UK): Care UK provides healthcare services at HMP Guys Marsh. In response to concerns about drug use, they have provided first aid training by prison staff and sourced posters highlighting the …
Overdue
Daphne Penn
Concerns: Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose reduction without sufficient clinical oversight.
Overdue
Angela West
Concerns: High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general ward and missing fluid balance charts, indicating dehydration issues.
Response (Barts NHS Trust): The out of hour’s surgical cover has been enhanced to ensure daily review of acute inpatients seven days a week, the junior doctor’s induction programme now contains a section around …
Responded
Michael Drewell
Concerns: A senior clinician's critical medication advice was not followed by a junior doctor, as it wasn't on electronic notes, highlighting a dangerous reliance on digital records over handwritten instructions.
Response (Leeds Teaching Hospitals NHS Trust): Leeds Teaching Hospitals NHS Trust will remind clinicians about the importance of robust handover and communication. They will also ensure individual clinicians prescribing 'off protocol' either action this themselves personally …
Responded
Cuthbert Hingert
Concerns: Significant medication errors, including duplicate prescribing and incorrect dosages, occurred due to clinicians failing to check databases and insufficient training. A nurse also failed to report these errors according to protocol.
Overdue
Gwyneth Edwards
Concerns: Inadequate weekend transfer protocols, staff failing to action NEWS scores, and a flawed Mobile Medic system marking incomplete requests as done, coupled with staffing pressures, jeopardized patient monitoring and record-keeping.
Overdue
Kalma Ram-Henman
Concerns: Multiple clinical failings included an incomplete fluid chart, unadministered essential medications and fluids despite orders, missed ECG abnormalities, and neglected opportunities to assess a deteriorating patient after transfer.
Response (Brighton and Sussex University NHS Trust): Brighton and Sussex University NHS Trust conducted team meetings and a Serious Incident Review Meeting to address inadequacies in the patient's care. They issued a Trust Safety Alert instructing staff …
Responded
Jacqueline Elliott
Concerns: Inadequate medication review processes, poor documentation, high-volume painkiller prescribing despite overdose history, and lack of continuity of care led to reliance on painkillers.
Response (Trafford CCG and Department of Health and Social Care): The CCG provides context on medication management practices, GP workload challenges and national initiatives to increase the GP workforce, but doesn't describe specific local actions.
Responded
John Thorp
Concerns: Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic formation due to stockings potentially not being given as prescribed.
Response (London North West University Healthcare NHS Trust): The Trust has introduced a new, standardised prescription chart with a section for TED stockings, including a venous thromboembolism risk assessment. Nurses must sign and date the chart daily to …
Responded
Malcolm Rathmell
Concerns: Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based pharmacy review, with proposed actions still in infancy.
Response (North East London NHS Foundation Trust): North East London NHS Foundation Trust will provide record keeping training to staff, develop and implement a discharge checklist, conduct audits, update the HTT Service Operational procedure, and update the …
Response (Department of Health and Social Care): The Department of Health and Social Care expresses sympathy and states that they expect the North East London NHS Foundation Trust to look carefully at the care provided and take …
Responded
CQC inspection actions(20)
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
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
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)
Article 2 learning points(1)
PHSO casework decisions(19)
P-002628 — Bradford Teaching Hospitals NHS Foundation Trust
Mr I complains the Trust missed several opportunities to review and prescribe his father’s regular medications between his admission in July and August 2021. He also complains about how the Trust investigated his complaint saying its response was contradictory and it felt like the Trust were not taking responsibility.
NHS in England
Partly Upheld
May 2024
P-003516 — Barnsley Hospital NHS Foundation Trust
Mr L complains about the care the Trust gave to his wife in August and September 2023. He complains about the medication prescribed, that doctors did not act quickly enough and that staff wrongly recorded she was allergic to flucloxacillin antibiotics.
NHS in England
Apr 2025
P-004507 — Northern Care Alliance NHS Foundation Trust
Ms D complains about several aspects of care provided to her father, Mr D, by Northern Care Alliance NHS Foundation Trust between October 2021 and July 2022. Ms D complains the Trust recommended Octasa as a suitable medication, when it is contraindicated in patients with blood clotting abnormalities; did not …
NHS in England
Upheld
Oct 2025
P-004204 — University Hospitals Birmingham NHS Foundation Trust
Mr H complains about the care and treatment he received from the University Hospitals Birmingham NHS Foundation Trust in 2021. He complains the Trust gave him incorrect instructions on how to take his medication, delayed scans, incorrectly prescribed medication, provided a lack of mobility treatment and communicated poorly.
NHS in England
Upheld
Oct 2025
P-001499 — United Lincolnshire Hospitals NHS Trust
Mr E complains that the Trust did not appropriately manage his late wife's nutritional needs and correctly administer her regular medication when she was an inpatient.
NHS in England
Aug 2022
P-001693 — Northampton General Hospital NHS Trust
Mr O complains the Trust made mistakes while he was an inpatient. He says it wrongly removed a nasogastric (NG) tube, failed to record an assault on him by another patient, did not update his clinical chart or give him a wristband to warn staff of his lactose intolerance.
NHS in England
Nov 2022
P-001929 — Lewisham and Greenwich NHS Trust
Ms T complains on behalf of her mother about how the Trust managed her seizures, medication and inflammation of the brain.
NHS in England
Partly Upheld
Apr 2023
P-001976 — University Hospitals Birmingham NHS Foundation Trust
Mrs N complains the Trust mismanaged her mother's condition and medication and that its communication was poor.
NHS in England
Apr 2023
P-002630 — A practice in the Sheffield area
Mrs L complains about different areas of the care and treatment the Practice gave to her husband between January 2022 and February 2023. She says it wrongly decided he did not have capacity, it did not monitor or follow up on his medication and it did not review him properly …
NHS in England
May 2024
P-003448 — East Sussex Healthcare NHS Trust
Miss B and her mother complain East Sussex Healthcare NHS Trust administered the wrong medication to Mr B just before he died, denied it gave him it and did not record this properly in the medication chart. They also complain it did not contact them soon enough when Mr B …
NHS in England
Partly Upheld
Mar 2025
P-004147 — Lancashire Teaching Hospitals NHS Foundation Trust
Miss U has raised concerns about the care her father, Mr U, received from the Trust. She highlights delays in administering aspirin following his stroke, inconsistent information about his diagnosis, an undocumented early withdrawal from an induced coma, and conflicting accounts provided during treatment and in the Trust’s complaint response.
NHS in England
Oct 2025
P-004423 — A practice in the City of Brighton and …
Mr M was on a daily dose of morphine. Mr M complains his GP Practice did not adequately communicate his medication changes with him.
NHS in England
Dec 2025
P-003865 — Portsmouth Primary Care Alliance Ltd
Miss G complains PPCA prescribed her father with antibiotics he had experienced side effects from before and it did not test his urine correctly.
NHS in England
Jul 2023
P-002349 — A practice in the Hertfordshire area
Mrs A complains the Practice did not assess her properly and dismissed symptoms of a stroke. She says it did not check her blood pressure, there was a delay in getting blister packs for her prescription medication and the Practice only agreed to prescribe them temporarily without any charges. She …
NHS in England
Nov 2023
P-002299 — An practice in the Northumberland area
Mr W complains the Practice made mistakes with how it managed his prescriptions.
NHS in England
Partly Upheld
Nov 2023
P-003221 — University Hospital Southampton NHS Foundation Trust
Mrs F complained the Trust did not manage her father’s warfarin safely and took too long to arrange a CT scan.
NHS in England
Not Upheld
Dec 2024
P-003604 — Frimley Health NHS Foundation Trust
Mrs J complains the Trust did not correctly handle her mother’s antibiotics between 12 and 15 November 2022. Mrs J also complains the Trust failed to correctly administer her mother’s Parkinson’s disease medication.
NHS in England
Jun 2025
P-001984 — The Princess Alexandra Hospital NHS Trust
Mr L complains about parts of the Trust's care and treatment from January to February 2022. He says its communication with the family was poor, it delayed diagnosing oral thrush, it prescribed the wrong medication and the nursing care was poor leading to a deterioration in his health.
NHS in England
May 2023
P-002697 — East Lancashire Hospitals NHS Trust
Miss N complains about how the Trust managed her father's care. She complains it made a DNACPR decision without any discussion with her father or the family, about delays in investigations, procedures and treatment, about a failure to follow up care plans, delayed access to a bed on a gastroenterology …
NHS in England
Partly Upheld
Jun 2024