Medication Contamination/Misadministration
Unexplained presence of an allergic medication in a patient's system, raising concerns about contamination or misadministration.
Source spread
Where this theme appears
This theme appears across 14 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
30 PFD reports
2 committee recs
10 HSSIB recs
23 CQC actions
3 PPO recs
47 IMB recs
1 IMB report
25 patient safety alerts
128 PHSO decisions
9 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Prevention of Future Deaths reports(30)
Frederick Davidson
Concerns: The coroner noted inadequate note-keeping practices and a communication breakdown between staff regarding nasogastric tube placement and feeding authorisation. Concerns were also raised about the delayed recognition of pneumothorax on X-ray and subsequent treatment.
Overdue
Norma Sheppard
Concerns: The coroner noted considerable confusion regarding Mrs Sheppard’s discharge terms, with the written discharge letter indicating continued subcutaneous fluids while the understanding upon discharge was that she would not receive them. This discrepancy created difficulties in finding a suitable care home.
Overdue
Michael Anthony
Concerns: The coroner identified high levels of Gabapentin in a diabetic patient, a drug generally not prescribed to diabetics due to severe reaction risks. Concerns were raised as the GP did not explain the rationale for this prescription.
Response (Guys St Thomas NHS Trust): • The Trust requested full disclosure of the toxicologist's report. • The Trust requested and received a review from the regional drug information service. • The Trust stated it had … (AI summary)
Overdue
Jessica Bond
Concerns: The coroner noted that Propess should not be administered to patients with a history of previous caesarean section or uterine surgery due to the risk of uterine rupture and associated obstetrical complications.
Overdue
Alan Peck
Concerns: A patient's prescribed medication was not delivered due to an unconnected syringe driver on a surgical ward, and the device was then not transferred with him to hospice, interrupting his essential pain relief.
Overdue
Elsie Mallalieu
Concerns: The patient's placement on an inappropriate ward, where staff lacked training for her high-flow oxygen and high workload impacted observations and record-keeping, raised concerns. Further issues included an inappropriate DNAR order, lack of escalation to higher care, and an unadministered antibiotic drip.
Response (Tameside Hospital NHS Trust): • Training has been provided to orthopaedic doctors regarding consultant involvement and documentation for patient transfers, and on appropriate patient movement from the Trauma Unit. A training schedule for Ward … (AI summary)
Responded
Marjorie Ellery
Concerns: The coroner raised concerns regarding the administration of medication to patients with known allergies without appropriate senior medical advice, and the need to ensure informed consent in such situations.
Response (Frimley Health NHS Trust): • The Trust decided that medication for patients with known allergies must be authorised by a registrar or above and documented, with informed consent obtained and recorded. • These changes … (AI summary)
Responded
Annette Charlton
Concerns: The coroner noted that manufacturers producing medications in almost identical packaging may contribute to dispensing errors and potentially to patient deaths.
Response (Crescent Pharma Limted): • Crescent Pharma Limited scheduled a meeting with the MHRA in January 2015 to discuss packaging redesign and the use of colour to differentiate products. • The company stated that … (AI summary)
Overdue
Lydia Corah
Concerns: The coroner identified an error where Mrs Corah underwent an X-ray intended for another patient, leading to treatment delay and unnecessary radiation exposure for her, and also adversely affecting the patient for whom the X-ray was originally requested.
Response: • The organisation strengthened induction training for new doctors regarding the Notis electronic requesting system. • An action plan derived from the radiography report was completed, which included staff reflection … (AI summary)
Responded
Sneh Chaudhry
Concerns: The coroner noted the similar appearance of Fungizone and Ambisome drug vials, which increases the risk of confusion and potential toxicity. Concerns were also raised regarding nursing checks being passive rather than active.
Overdue
Marie Millward-Winter
Concerns: The coroner noted concerns regarding ambulance technicians administering anticoagulation medication (Apixaban) to Mrs Millward Winter after a head injury. This administration worsened an internal bleed and contributed to her death.
Response (North West Ambulance Service NHS Trust): • The Trust's Head of Legal Services interviewed the attending crew member to obtain an account of discussions with nursing home staff regarding medication administration. • An Advanced Paramedic reviewed … (AI summary)
Responded
Gabriele Kreichgauer
Concerns: Concerns were raised about the lack of a final treatment check, resulting in the patient not receiving antibiotics. The coroner also noted a misdiagnosis of an infected cat bite due to an online resource not adequately distinguishing it from cat scratch fever, and the absence of a feedback mechanism within that resource.
Overdue
KennethDaly
Concerns: The consultant's advice to the GP regarding the continuation of certain pain medications was unclear, and the GP did not seek further guidance. The patient did not receive tailored written advice on his pain relief regimen or the risks of combining multiple opioid medications.
Response (Rochdale Boroughwide Housing Limited): • Rochdale Boroughwide Housing stated it would not consider a wholesale installation programme for carbon monoxide detectors until the outcome of a government review is known. • The organisation will … (AI summary)
Overdue
Doris Clark
Concerns: A doctor prescribed morphine without knowing the dose already given by paramedics. The coroner identified a risk arising from the differing units of measurement for opiate medication used by pre-hospital and hospital services.
Overdue
Colin Beaumont
Concerns: The coroner noted concerns regarding the misplacement of a nasogastric tube twice in the same patient, which resulted in pneumothorax and contributed to death.
Response (South Warwickshire NHS Foundation Trust): • The Trust stated its policy for nasogastric tube insertion would be amended to require a review of alternative feeding options and further risk discussion if a tube cannot be … (AI summary)
Responded
Ashley Walker
Concerns: The coroner identified a communication error that confused ingestion with spillage and noted that an effective antidote for toxicity was not available on the ambulance.
Response (West Midlands Ambulance Service): • Staff were instructed to remove the WISER App from work mobile devices, with its use restricted to trained Tactical Incident Commanders, National Inter-Agency Liaison Officers, and Hazardous Area Response … (AI summary)
Responded
Jerome Peat
Concerns: The EMIS computer medical record system did not alert medical staff to a duplicate patient registration, leading to an inadvertent duplication of morphine prescriptions.
Overdue
Michele Duckworth
Concerns: The deceased was incorrectly prescribed Tazocin when colonised with ESBL, contrary to trust guidelines, and this error was not identified during multiple medical reviews.
Overdue
Ian Hall
Concerns: The coroner noted it was unclear how Amitriptyline was dispensed instead of Atenolol. Concerns were raised about the lack of clarity regarding pharmacy checks to prevent incorrect medication dispensing, particularly when medication is administered by non-clinically trained carers to vulnerable adults.
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) stated it had previously issued best practice guidance to the pharmaceutical industry on differentiating medicines by colour to reduce the likelihood … (AI summary)
Overdue
John Skinner
Concerns: A junior doctor misheard a senior colleague's verbal instruction for phenytoin dosage, leading to a significant overdose. The coroner noted the risk of confusion from similar-sounding numbers in verbal communication within hospitals.
Overdue
Lily Girton
Concerns: The coroner raised concerns about inadequate staffing levels across CAMHS services, specifically noting a shortage of doctors, psychiatrists, and nurses. This resulted in consultant caseloads substantially exceeding recommended levels, posing a risk of future deaths among young people.
Overdue
Anita Graves
Concerns: The coroner identifies risks of inadvertent overdose due to the visual similarity of different strength carbimazole tablets and their resemblance to aspirin. The community dispensing process for carbimazole does not adequately mitigate this risk.
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) conducted a review of authorised carbimazole products and their labelling. • The MHRA has published and updated guidelines for the pharmaceutical … (AI summary)
Responded
Rachel Edwards
Concerns: The report describes Rachel's informal admission to the Woodlands mental health ward in Ipswich on March 6th, 2017, following a significant overdose.
Response (Norfolk and Suffolk NHS Foundation Trust): • The Trust stated it would assess medications prescribed upon discharge and is completing a thematic review of deaths where prescribed medication was a cause. • The Trust confirmed it … (AI summary)
Responded
Paul Holmes
Concerns: The coroner noted a lack of clear and detailed handover between doctors during a patient's transfer, an unagreed treatment plan, and insufficient documentation. A prescription error also delayed the administration of hydrating fluids.
Overdue
David Martin
Concerns: The coroner noted inadequate induction for a long-term locum doctor regarding specific cardiology policies. There were also missed opportunities to identify incorrect patient medication, even after the oversight was recognised by staff.
Response (Royal Cornwall Hospitals): • The Trust reviewed and amended the wording in the PCI pack regarding Dual Anti-Platelet Therapy. • Revised wording was approved by the Safer Surgery Group and Forms Review Group, … (AI summary)
Responded
Susan Young
Concerns: The coroner noted a lack of clinical handover to the receiving ward and no doctor's instructions for cardiac monitoring. The patient's medication was found in her belongings, allowing an opportunity for further overdose.
Response (James Paget University NHS Foundation Trust): • Training on the transfer checklist and patient transfer and escort policy has been completed for 68% of Emergency Department staff, with bespoke sessions planned for those who could not … (AI summary)
Response (James Paget University Hospitals NHS Foundation Trust): • The Trust completed transfer training for Emergency Department staff, covering the patient transfer and escort policy and the use of the transfer checklist. • The Trust implemented a new … (AI summary)
Responded
Aaron Atkinson
Concerns: Concerns were raised about the lack of annual ECGs during GP reviews for individuals prescribed long-term anti-psychotic medication. This appears to stem from a lack of clarity and consistency in national and local guidance regarding the recognised cardiac risks.
Response (National Institute for Health and Care Excellence): • The National Institute for Health and Care Excellence (NICE) shared the Prevention of Future Deaths report with Agilio Software. • Agilio Software will add wording to the Clinical Knowledge … (AI summary)
Response (NHS Derby and Derbyshire Integrated Care Board): • The Integrated Care Board (ICB) stated it would amend its local Joint Area Prescribing Committee (JAPC) guidance to advise annual electrocardiogram (ECG) monitoring for all patients on antipsychotics after … (AI summary)
Responded
Dominic Philip
Concerns: The coroner raises concerns about the absence of pre-screening for contrast medium allergies in patients who have not previously had it, and the unexplained presence of Lidocaine in the deceased's system despite a known allergy and no documented administration.
Response (Medicines Healthcare Products Regulatory Agency): • The Medicines Healthcare Products Regulatory Agency (MHRA) will continue to monitor and review adverse event reporting for contrast media as part of its pharmacovigilance activities. • The MHRA will … (AI summary)
Response (The Royal College of Radiologists): • The Royal College of Radiologists (RCR) has established a working party to develop guidance on the administration of iodinated contrast medium (ICM) and gadolinium. • The RCR anticipates this … (AI summary)
Response (University Hospitals of Northamptonshire NHS Group): • The trust stated that routine allergy testing prior to CT contrast studies is not considered viable, citing low incidence of severe reactions, lack of reliable tests, and significant resource … (AI summary)
Response (Department for Health and Social Care): • The Department for Health and Social Care indicated that other agencies were best placed to respond directly to the issues raised. • The Department for Health and Social Care … (AI summary)
Responded
Sidra Aliabase
Concerns: The coroner identified gaps in communication within the paediatric cardiology team and with other hospitals, noting a lack of early planning systems for diagnosing long QT in at-risk newborns. Concerns were also raised about the potential for drug selection errors due to drop-down menu prescribing.
Response (Great Ormond Street Hospital for Children NHS Foundation Trust): • The Trust has doubled the number of resident doctors covering external cardiology calls during the day since July 2025. • The Trust is implementing a new online patient referral … (AI summary)
Response (Chelsea and Westminster Hospital): • The Trust is updating its guideline to ensure multidisciplinary teams consider earlier appointments for mothers at risk of pre-term labour. • The Trust is developing a new guideline for … (AI summary)
Responded
Moira Parker
Concerns: The coroner noted that an occupational health referral was not made, which would have triggered a stress risk assessment and support. Concerns were also raised about staff knowledge and training regarding occupational health referral procedures and available support.
Response (Unilever Plc): • Leaders and line managers at Colworth Science Park attended mental health awareness and upskilling sessions. • An external consultancy delivered a mandatory in-person session for leaders and line managers … (AI summary)
Responded
Select committee recommendations(2)
#53 — Change public health guidance for diamorphine provision to allow multi-dose vials.
Recommendation: We recommend that public health guidance on the provision of diamorphine be changed to allow for the use of multi-dose vials instead of single-use ampoules to mitigate the additional cost and supply chain pressures associated with single-use ampoules.
Response attribution not verified
#50 — Ensure sustainable supply of prescribed diamorphine for patients facing shortages.
Recommendation: We are concerned by reported shortages of prescribed diamorphine, particularly because of the serious impact they may have on the health and lives of patients. As prescribed diamorphine is a viable form of treatment in England, the Government must work …
Response attribution not verified
HSSIB safety recommendations(10)
Never events: analysis of HSIB's national investigations
Inadvertent administration of an oral liquid medicine into a vein (Healthcare Safety Investigation Branch, 2019d).
Learning Prompt
Never events: analysis of HSIB's national investigations
Prescribing and administering insulin from a pen device in hospital (Healthcare Safety Investigation Branch, 2019c).
Learning Prompt
Residual drugs in intravenous cannulae and extension lines
Flushing is a key mitigation for preventing the risk of residual drugs in cannulae and extension lines. However, it sits at the ‘administrative controls’ level of the hierarchy of hazard control, towards the ‘least effect’ end of the control spectrum …
Learning Prompt
Residual drugs in intravenous cannulae and extension lines
This is particularly the case for drugs that can cause a clinically significant effect in low volumes.
Learning Prompt
Residual drugs in intravenous cannulae and extension lines
One of the key risk factors associated with residual drugs in cannulae and extension lines is the concentration and risks associated with the drug itself.
Learning Prompt
Unintentional overdose of morphine sulfate oral solution
It may be beneficial if manufacturers of morphine oral solution 10mg in 5ml ensure that any dose measurement aid, if supplied with the medication, is able to measure a full range of possible doses. The intention of this safety observation …
Safety Observation
The use of an appropriate flush fluid with arterial lines
It may be beneficial to consider how the design processes and guidance for blood glucose recording can support identification and early warning of a potential blood sample contamination by flush fluid.
Safety Observation
The use of an appropriate flush fluid with arterial lines
HSIB recommends that the Care Quality Commission reviews the recommendations from the Association of Anaesthetists on how to manage the risks of contamination by the flush fluid when using an arterial transducer line and determines any appropriate actions for the …
Safety Recommendation
The use of an appropriate flush fluid with arterial lines
HSIB recommends that the Association of Anaesthetists works with relevant professional organisations to revise existing national guidance to manage the risks of contamination by the flush fluid when using an arterial line to take a blood sample.
Safety Recommendation
The use of an appropriate flush fluid with arterial lines
HSIB recommends that the Department of Health and Social Care, once post-market surveillance data is available, involves relevant stakeholders including the Association of Anaesthetists’ review and determine appropriate actions that could be taken to further mitigate the risk of blood …
Safety Recommendation
NCEPOD recommendations(1)
CQC inspection actions(23)
St Richard's Hospital
The trust must ensure that medicines are used once opened in line with manufacturers guidance.
Must Do
Doncaster Royal Infirmary
The trust must ensure staff follow the proper and safe management of medicines, and the service uses systems and processes to prescribe and administer medicines safely.
Must Do
Chorley and South Ribble Hospital
The service must ensure patients receive antimicrobials in line with the national guidelines.
Must Do
Stamford & Rutland Hospital
The service must ensure the expressed breast milk fridge is locked to reduce the risk of milk being tampered with.
Must Do
St Albans City Hospital
The trust should ensure that patients are weighed to facilitate medication dosing (Regulation 12).
Should Do
Royal Hallamshire Hospital
The trust must ensure that staff follow systems and processes to prescribe and administer medicines safely.
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
North Manchester General Hospital
The trust should ensure that ambient room temperatures for storage of medicines should be consistently measured and recorded.
Should Do
North Manchester General Hospital
The trust should ensure effective expiry date medicine management and that fridge temperatures are in line with legislative standards.
Should Do
North Manchester General Hospital
The trust should ensure medicine fridge and room temperatures in the surgical assessment unit are in line with guidelines.
Should Do
North Manchester General Hospital
The trust should ensure that all medications for use in the clinical areas are within the agreed expiry date for safe use.
Should Do
Mount Vernon Cancer Centre
The trust must ensure that all staff follow medicines management policies and procedures when administering, recording and storing medicines.
Must Do
Mount Vernon Cancer Centre
The service must ensure that there are systems and processes in place to safely prescribe, administer and record medicines.
Must Do
Andover War Memorial Hospital
The trust must have clear processes for checking expiration dates, storing medication and recording fridge temperatures.
Must Do
Rotherham General Hospital
The trust should ensure that the standard operating policy for over labelled take home medicines is introduced and becomes fully embedded practice.
Should Do
Kettering General Hospital
The servicemust ensure staff always follow the correct processes when administering and storing medicines.
Should Do
Gloucestershire Royal Hospital
The trust must ensure that staff follow trust policies and procedures when administering medications.
Must Do
Cumberland Infirmary
The trust must ensure that controlled drug and other medications should be stored correctly and securely. Regulation 12(1)(2)(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
Cumberland Infirmary
The trust must ensure that all medicines are stored in accordance with temperature thresholds to ensure efficacy of medication is not impacted upon. Regulation 12(1)(2)(g).
Must Do
Chorley and South Ribble Hospital
The trust should monitor and review arrangements to ensure that medicines with a minimum dosage interval are administered as prescribed.
Should Do
Chorley and South Ribble Hospital
The trust should monitor and review arrangements to ensure that medicines with a minimum dosage interval are administered as prescribed.
Should Do
PPO death in custody recommendations(3)
The Head of Healthcare
The Head of Healthcare should ensure that there is an effective recall system for patients receiving regular injections such as Prostap.
The Governor
The Governor should ensure that the diversion and trading of prescribed medication is fully addressed in the prison’s local drug strategy; medication dispensing is supervised at all times, in line with the local policy; and guidance is issued on effective …
The Director General of HMPPS
The Director General of HMPPS should amend the Prisoners’ Property Policy Framework to make specific reference to prisoners’ medication in the cell clearance section.
IMB individual recommendations(47)
Drake Hall (2024)
The Board is concerned about the ongoing problems regarding medication management. This has three components: o The process for administration of medications needs a complete and radical overhaul. o A means of controlling prescription medication needs to be found to reduce the risks associated with trading medications. o The design of the dispensary does not facilitate the effective administration of …
Governor / Director
Berwyn (2020)
Inpatient units/Medication Policy
NHS / Healthcare Provider
Partially Accepted
Berwyn (2020)
Medication Policy issues
NHS / Healthcare Provider
In Progress
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That the administration of detainees’ personal prescribed medication in airport HRs be resolved forthwith.
Home Office
Bedford (2021)
There are issues around the dispensing of medication that need resolving. Some prisoners are not receiving their medication, while others may be selling it on, as there has been inadequate supervision at the pharmacy.
Governor / Director
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
North West and Midlands STHF (2023)
For the fifth year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detained individuals with access to their prescribed medication. The Board continues to note that the welfare of detained individuals has been adversely affected by this situation. This occurs particularly in holding rooms and …
Ministry of Justice
North East Midlands, Yorkshire & Humber STHF (2023)
We recommend that Home Office policy be immediately amended to enable staff in STHFs to continue removing medicine from the possession of those detained but to allow them to permit the person detained to take a required dose at intervals as per the prescription or pharmaceutical product recommendations. We judge that permitting single doses is important for preventing any risk …
Home Office
Hollesley Bay (2023)
A review of the arrangements for dispensing medication is requested. The current regime is slow and cumbersome, which causes frustration for prisoners and friction with healthcare staff.
Governor / Director
Forest Bank (2024)
The Board has received complaints about medication treatment dispensing times being missed frequently, which has an impact on prisoners’ health. What action will the prison take to improve this outcome?
Governor / Director
Stafford (2020)
Will the Governor Ensure that the orders already issued regarding the supervision of medicine queues are adhered to at all times
Governor / Director
Oakwood (2020)
The Director should ensure that officers are present at the medicine hatches during the dispensing of medication.
Governor / Director
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
Stafford (2021)
Will HMPPS ensure that HMP Stafford and Practice Plus Group initiate, with immediate effect, a medicines management system that, unlike now, does not impair the safety of its residents and is put under close supervision until ALL previous recommendations (PPO, CQC, HMIP, etc.) have been fully and successfully delivered?
HMPPS
In Progress
Scotland and Northern Ireland Short-Term Holding Facilities (2022)
We would urge the Minister to request that the Home Office carry out an urgent assessment of the risks to detained people as a result of the removal of their prescription medications. These risks should then be taken into account when designing a practical strategy for ensuring that detained people receive their appropriate medication. The desired outcome would be that …
Other
North and Midlands Short Term Holding Facilities (2022)
For the fourth year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detained individuals with access to their prescribed medication. The Board continues to note that the welfare of detained individuals has been adversely affected by this situation. This occurs particularly in holding rooms and …
Home Office
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
Styal (2023)
The Board continues to have concerns around the safe and timely administration and dispensing of medication. What will be done to address the inadequate accommodation for the pharmacy service including the way in which medicines, including methadone, are transported?
HMPPS
Lewes (2023)
Will the Governor ensure that all prison staff are aware of the importance of supervising dispensary hatches?
Governor / Director
Wandsworth (2024)
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
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
Feltham (2024)
When will the Traka units for dispensing medication be commissioned for use?
Governor / Director
Cardiff (2024)
The Board again wishes to highlight applications about medication/ prescriptions continue to be received at a very high level and recommends further consideration be given to addressing this.
NHS / Healthcare Provider
In Progress
Bronzefield (2024)
What plans does the prison have to work more effectively with CNWL and Forward Trust to improve the timely dispensation of medication? (6.1)
Governor / Director
Send (2025)
Poor communication has led to delays in the provision of medication to newly arrived prisoners (6.1).
HMPPS
Implemented
Berwyn (2025)
If prisoners arrive late on Fridays, the pharmacist will not be available until the Monday. This is a major issue, as it means that medication cannot be dispensed over the weekend.
HMPPS
Implemented
Heathrow Short Term Holding Facility (2020)
The Home Office should ensure that the new system is provided as quickly as possible to ensure that people in detention can access their own prescription medication and common non-prescription medication (paras. 9.2 - 9.5; 18.2 – 18.3; 26.2; 34.2).
Home Office
Durham (2020)
Why are incidents of prisoners missing three consecutive days of medication no longer reported?
Governor / Director
Wayland (2022)
The Board suggests there may be a need to review how the medication periods are managed and supervised, especially considering instances of violence in the drug dependency medications queue and policy of prescription reduction.
Governor / Director
Gatwick, Stansted, Luton and Lunar House (2022)
As stated above, at Gatwick, Luton, and Stansted airports, dedicated medical practitioners should be available, on a 24/7 basis to, where appropriate, authorise the taking of their own medication by detained individuals, or where there is an urgent need, to prescribe medication.
NHS / Healthcare Provider
Gatwick, Stansted, Luton and Lunar House (2022)
at Gatwick, Luton, and Stansted airports, dedicated medical practitioners should be available, on a 24/7 basis to, where appropriate, authorise the taking of their own medication by detained individuals, or where there is an urgent need, to prescribe medication.
Other
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)
The Minister is urged to request that the Home Office carry out an urgent assessment of the risks to detained people as a result of the removal of their prescription medications. These risks should then be taken into account when designing a practical strategy for ensuring that detained people receive their appropriate medication. The desired outcome would be that the …
Other
Rye Hill (2023)
The Board is concerned that processes designed to ensure prisoners have sufficient prescribed medication with them when transferring to Rye Hill are not being consistently applied across the prison estate.
HMPPS
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
North East Midlands, Yorkshire & Humber STHF (2024)
We repeat our recommendation that the policy be immediately revised to allow staff in STHFs to permit the person detained to take a required dose at intervals as per the prescription or pharmaceutical product recommendations. We judge that permitting single doses is important for preventing any risk of health deterioration and for being fair and humane, while minimising any adverse …
Home Office
Featherstone (2024)
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
Wymott (2025)
The report raises a number of concerns about the delivery of medication and essential repairs to the fabric of the prison. What will the Governor do to ensure that the service provided by external agencies (such as Practice Plus Group, Amey) is of an acceptable standard?
Governor / Director
In Progress
Durham (2025)
The Board has observed the lack of supervision of medication queues throughout the year. How will the Governor ensure that staff are deployed to maintain adequate supervision?
Governor / Director
Durham (2025)
The Board has observed the lack of supervision of medication queues throughout the year. How will the Governor ensure that staff are deployed to maintain adequate supervision?
Governor / Director
Belmarsh (2025)
Will the Governor continue to work with Practice Plus Group to improve the management and dispensing of medication within the prison?
Governor / Director
In Progress
Foston Hall (2023)
The medication dispensing hatch remains unfit for purpose, with prisoners queuing outside in all weathers and not being assured of privacy if the queue isn’t well-managed. When will this be addressed?
Governor / Director
Drake Hall (2023)
More ways of controlling prescription medication need to be found to reduce the risks associated with trading medications.
Governor / Director
Five Wells (2025)
How are the new lockable lockers having an impact on the dispensing of medication?
Governor / Director
Five Wells (2025)
How are the new lockable lockers having an impact on the dispensing of medication?
Governor / Director
Featherstone (2020)
While the performance of healthcare staff appears adequate, there are a number of concerns: attendance at segregation reviews and use of force incidents; the monitoring of self-dispensing of medication held by prisoners; the operation of the healthcare complaints procedure; the thoroughness of mental health reviews and the reporting relationship with general healthcare. Can the Governor discuss these shortcomings with the …
Governor / Director
Feltham (2025)
Commission the Traka units for dispensing medication for use (Feltham B Governor).
Governor / Director
Bronzefield (2025)
What plans does the prison have to continue to improve co-ordination between the prison and NHS bodies in the timely dispensing of medications and the treatment of very unwell prisoners (6.1)?
Governor / Director
In Progress
National patient safety alerts(25)
Class 1 Medicines Recall: Quetiapine Oral Suspension by Eaststone Limited - potential overdosing
Jan 2026
NatPSA/2026/002/MHRA
Contamination of non-sterile alcohol-free skin cleansing wipes with Burkholderia spp
Jun 2025
NatPSA/2025/002/UKHSA
Risk of oxytocin overdose during labour and childbirth
Sep 2024
NatPSA/2024/010/NHSPS
Inappropriate dosing risk when switching insulin degludec (Tresiba) products
Dec 2023
NatPSA/2023/016/DHSC
Contamination of carbomer-containing lubricating eye products with Burkholderia cenocepacia
Dec 2023
NatPSA/2023/015/UKHSA
Potential risk of underdosing with calcium gluconate in severe hyperkalaemia
Jun 2023
NatPSA/2023/007/MHRA
Steriflex Potassium Chloride, Sodium Chloride and Glucose IV fluid bags
Jan 2026
NatPSA/2026/001/DHSC
Supply of Licensed and Unlicensed Epidural Infusion Bags
Dec 2025
NatPSA/2025/007/DHSC
Shortage of bumetanide 1mg tablets
Jul 2025
NatPSA/2025/003/DHSC
Discontinuation of Promixin (colistimethate) powder for nebuliser solution
Mar 2025
NatPSA/2025/001/DHSC
Shortage of Pancreatic enzyme replacement therapy (PERT) - Additional actions
Dec 2024
NatPSA/2024/013/DHSC
Shortage of Molybdenum-99/Technetium-99m generators
Oct 2024
NatPSA/2024/012/DHSC
Discontinuation of Kay-Cee-L (potassium chloride) syrup
Oct 2024
NatPSA/2024/011/DHSC
Shortage of Human Albumin 4.5% and 5% dose vials
Jul 2024
NatPSA/2024/009/DHSC
Shortage of Kay-Cee-L (potassium chloride) syrup
Jul 2024
NatPSA/2024/008/DHSC
Shortage of Pancreatic enzyme replacement therapy (PERT)
May 2024
NatPSA/2024/007/DHSC
Shortage of Orencia ClickJect (abatacept) 125mg pre-filled pens
May 2024
NatPSA/2024/006/DHSC
Shortage of Erelzi (etanercept) 50mg pre-filled pen
May 2024
NatPSA/2024/005/DHSC
Shortage of salbutamol nebuliser liquid unit dose vials
Feb 2024
NatPSA/2024/003/DHSC
Shortage of GLP-1 receptor agonists (update)
Jan 2024
NatPSA/2024/001/DHSC
Shortage of verteporfin 15mg powder for solution for injection
Sep 2023
NatPSA/2023/012/DHSC
Shortage of ADHD medications (methylphenidate, lisdexamfetamine, guanfacine)
Sep 2023
NatPSA/2023/011/DHSC
Shortage of GLP-1 receptor agonists
Jul 2023
NatPSA/2023/008/DHSC
Shortage of pyridostigmine 60mg tablets
May 2023
NatPSA/2023/006/DHSC
Shortage of Antimicrobial Agents Used in Tuberculosis (TB) Treatment
Jul 2025
NatPSA/2025/004/DHSC
Health investigations(6)
Independent investigation: Philip Slater, Silsden (2017) — Rec 8
NHS England should report the findings of this report that relates to the dispensing error to the Royal Pharmaceutical Society and the General Pharmaceutical Council.
north_east_yorkshire
An independent investigation into the care and treatment of mental … — Rec 8
NHS England should report the findings of this report that relates to the dispensing error to the Royal Pharmaceutical Society and the General Pharmaceutical Council.
Published 30 March 2022 This is the extended executive summary of the independent investigation into the care and treatment of Mr G. Bradford District Care NHS Foundation Trust
north_east_yorkshire
An independent external quality assurance review of the internal investigation … — Rec 8
Prolonged intervals between depot medications. A missed depot medication in May/June 2017 was not identified. Inappropriate actions following a seizure in a patient on depot medication. A quality peer review team will review the function of the recovery team (as above).
north_west
Independent investigation: Warren Duke, Slough (but Tees patient) (2015) — Rec Recommendation 5
TEWV must review the TEWV CPA policy to ensure that overdue depot medication is communicated effectively in referral procedures and correspondence, e.g. by ‘phone.
north_east_yorkshire
An independent investigation into the care and treatment of Miss … — Rec 5
The Trust must provide assurance that nursing staff adhere to best practice guidance in the administration of depot injections and the requirements of the Safe Secure Handling of Medicines Policy in the care of patients receiving antipsychotic medication.
Miss B was convicted of murder in December 2015. At the time of the homicide Miss B was receiving care and treatment from Rotherham, Doncaster and South Humber NHS Foundation Trust
north_east_yorkshire
An independent external quality assurance review of the internal investigation … — Rec 3
Record keeping gaps, delays, records created and amended after index offence, missed depot May/June, 28/30 June, risk assessment updated after index offence. Entries onto the electronic record at the time of booking psychiatric review appointments. A quality peer review team will review the function of the recovery team (as above).
north_west
PHSO casework decisions(128)
P-001392 — Royal Free London NHS Foundation Trust
Mrs E complained her husband was given an excessive chemotherapy dose while infected, which worsened his condition and caused an earlier death.
NHS in England
Upheld
May 2022
P-004438 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs O complained her husband was wrongly administered goserelin intended for another patient, causing him significant side effects and contributing to his distress.
NHS in England
Upheld
Nov 2025
P-004653 — United Lincolnshire Teaching Hospitals NHS Trust
The Trust failed to provide her father's lupus medication, unsafely discharged him, and delayed its complaint response due to lost medical records, causing distress and worsening his condition.
NHS in England
Partly Upheld
Jan 2026
P-001072 — Manchester University NHS Foundation Trust
Ms A complained her deceased brother’s NG tube was wrongly inserted, causing fluid to enter his lung and contributing to his death. She also alleged poor communication about his cardiac arrest and inconsiderate handling of tissue donation.
NHS in England
Upheld
Jun 2021
P-001648 — University Hospitals of North Midlands NHS Trust
The complainant alleged the Trust incorrectly administered a fentanyl patch, leaving her mother without pain relief and causing distress, alongside poor record-keeping.
NHS in England
Oct 2022
P-001695 — The Dudley Group NHS Foundation Trust
Miss I complained about incorrect medication, delayed antibiotics, not allowing a relative to attend tests, problems during a swallowing test, and failure to perform a post-mortem on her grandmother.
NHS in England
Nov 2022
P-001620 — University Hospitals of North Midlands NHS Trust
Mrs A complained about inappropriate medication, inappropriate administration of antibiotics, and delays in antibiotics for her mother's end-of-life care, causing a horrific death.
NHS in England
Nov 2022
P-003849 — A practice in the Wigan area
A GP practice issued several incorrect prescriptions in October 2022, which could have led to an overdose.
NHS in England
Sep 2023
P-002644 — A practice in the Bournemouth area
Ms F complained a doctor wrongly administered a second Vaxzevria COVID-19 vaccine dose instead of Pfizer, after she suffered a 'stroke' from the first Vaxzevria, leading to new stroke symptoms and disability.
NHS in England
May 2024
P-002693 — Imperial College Healthcare NHS Trust
Mr H complained the Trust inappropriately administered alteplase and damaged an artery during a procedure on his father, leading to a brain haemorrhage and death.
NHS in England
Jun 2024
P-002876 — Warrington and Halton Hospitals NHS Foundation Trust
Mr P complained staff gave him flucloxacillin despite an allergy and about poor nursing management of his skin condition dressings, causing pain and scarring.
NHS in England
Partly Upheld
Aug 2024
P-003175 — East Suffolk and North Essex NHS Foundation Trust
Miss R complained the Trust administered morphine to her mother despite knowing of an allergy, provided poor emergency care, and believed it caused her mother's death.
NHS in England
Nov 2024
P-003199 — Hampshire Hospitals NHS Foundation Trust
Mrs O complained her husband received a Lidocaine overdose ten times the correct dose, believing it significantly contributed to his death.
NHS in England
Dec 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-003666 — Great Western Hospitals NHS Foundation Trust
Mr F complained staff gave his father poor nutrition/fluids, inadequate mouthcare, left him without oxygen, and administered allergic antibiotics, which he believes led to his father's avoidable death.
NHS in England
Jul 2025
P-004160 — Mid and South Essex NHS Foundation Trust
Mrs G complained the Trust administered dapagliflozin without monitoring, failed to provide nutrition, and delayed Mr G's bypass surgery, leading to HHS, a heart attack, and his death.
NHS in England
Partly Upheld
Oct 2025
P-004329 — United Lincolnshire Teaching Hospitals NHS Trust
Mrs D complained the Trust prescribed her triple the correct dose of breast cancer treatment, abemaciclib, causing debilitating side effects. This impacted her quality of life and trust in the NHS.
NHS in England
Partly Upheld
Nov 2025
P-004443 — The Royal Wolverhampton NHS Trust
Mr A complained the Trust gave his mother penicillin despite her allergy and chronic kidney disease, causing irreversible damage and her death a month later.
NHS in England
Dec 2025
P-004685 — A practice in the Chichester area
Mrs A complained a Pharmacy issued incorrect medication leading to her daughter's overdose, and a Practice did not arrange an urgent GP appointment for her subsequent symptoms.
NHS in England
Jan 2026
P-004606 — A practice in the Sandwell area
Miss L complained the Trust misdiagnosed her severe headaches and delayed further investigations, including an MRI, between January and August 2021 due to a misreported CT scan, causing unnecessary pain and suffering.
NHS in England
Upheld
Jan 2026
P-004599 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
The Trust inappropriately prescribed a 'dangerous concoction' of medication, not in line with guidance, causing multiple side effects.
NHS in England
Jan 2026
P-001074 — Harrogate and District NHS Foundation Trust
Mrs A complained about her father's care, including late Parkinson's medication, several falls (one causing a fractured hip), severe pressure ulcers, and the Trust's inadequate investigation of these incidents.
NHS in England
Partly Upheld
Jun 2021
P-001084 — Pennine Acute Hospitals NHS Trust
Miss B complained her mother was given midazolam, believing it caused a comatose state and premature death, and medical records were incomplete.
NHS in England
Not Upheld
Jul 2021
P-001184 — Wirral University Teaching Hospital NHS Foundation Trust
Miss R complained the Trust used incorrect antibiotics for her father's sepsis, a healthcare assistant gave him food when nil by mouth, and nursing staff failed to administer prescribed laxatives.
NHS in England
Partly Upheld
Nov 2021
P-001289 — The Dudley Group NHS Foundation Trust
Daughter complained her mother's chronic diarrhoea and SIBO were not appropriately treated, and medication for Parkinson's, pain, and anxiety was incorrectly administered.
NHS in England
Partly Upheld
Feb 2022
P-001385 — Lewisham and Greenwich NHS Trust
Ms E complained the Trust gave her incorrect treatment, documented incorrect medication information, lost ECG reports, and failed to respond to her further concerns, causing her and her daughter PTSD.
NHS in England
May 2022
P-001559 — West Hertfordshire Hospitals NHS Trust
Mrs A and Mrs Y complained about Mr Y's stroke and cancer care, alleging medication errors, missed stroke symptoms, delayed cancer diagnosis, and poor complaint handling, leading to severe disability and death.
NHS in England
Partly Upheld
Sep 2022
P-003901 — North Middlesex University Hospital NHS Trust
Mr A complained the Trust caused his mother's unexpected death on 6 April 2021 by giving her three different medications. He sought an investigation and financial payment.
NHS in England
Jul 2023
P-002303 — South West Yorkshire Partnership NHS Foundation Trust
Miss H complained the Trust's consultant psychiatrist changed her medication and refused to revert it, which she believes led to her mental health deteriorating and being sectioned.
NHS in England
Upheld
Nov 2023
P-002335 — East Kent Hospitals University NHS Foundation Trust
Mrs T complained her mother was incorrectly given glucose gel while semi-unconscious and not treated for coughing. She alleged this caused lung damage, delayed treatment, and led to her mother's death.
NHS in England
Dec 2023
P-002383 — Black Country Healthcare NHS Foundation Trust
Mr A alleged the Trust wrongly prescribed his mother 8mg of Risperidone, causing brain damage, speech issues, sleep apnoea, and requiring full-time home care.
NHS in England
Dec 2023
P-002359 — University College London Hospitals NHS Foundation Trust
Mr A complained about the Trust's treatment of his wife, specifically a mistaken 100mg hydrocortisone injection, which he believes contributed to her death.
NHS in England
Dec 2023
P-002507 — Sheffield Teaching Hospitals NHS Foundation Trust
Miss E complained the Trust gave her mother an iron infusion too quickly, which she believed worsened her mother's pulmonary fibrosis and led to an earlier death.
NHS in England
Mar 2024
P-002570 — Great Ormond Street Hospital for Children NHS Foundation …
Mr S complained his son received an inappropriate immunoglobulin dose, wrong treatment, and improper oxygen, contributing to his son's avoidable death.
NHS in England
Apr 2024
P-002616 — South Tyneside and Sunderland NHS Foundation Trust
Mr A complained the Trust improperly extended his chemotherapy cream use beyond recommended limits and provided no warnings, resulting in a permanent facial disfigurement.
NHS in England
May 2024
P-002643 — Croydon Health Services NHS Trust
Mrs L complained the Trust failed to keep her husband isolated, withheld diabetes medication and antibiotics, and cancelled a lung drainage procedure, contributing to his death from pneumonia.
NHS in England
May 2024
P-002999 — Sherwood Forest Hospitals NHS Foundation Trust
Mrs E and Ms P complained the Trust wrongly stopped Mr W’s medication and gave a partial thrombolysis dose, causing him to suffer a stroke and severe disability.
NHS in England
Sep 2024
P-002909 — Mid Cheshire Hospitals NHS Foundation Trust
Mrs O complained the Trust delayed referring her father to speech and language therapy, inappropriately changed his fluid provision, failed to keep him nil by mouth, and inserted an NG tube without consent.
NHS in England
Upheld
Sep 2024
P-003202 — Blackpool Teaching Hospitals NHS Foundation Trust
Mr R complained the Trust gave his mother incorrect doses of Midazolam, did not discuss a Do Not Attempt Resuscitation Order, and wrongly placed her on end-of-life care.
NHS in England
Not Upheld
Dec 2024
P-003542 — George Eliot Hospital NHS Trust
Mr and Mrs G alleged incorrect antibiotics and unsafe travel advice led to their son's severe wound infection and hospitalisation abroad. They sought financial redress for lost earnings.
NHS in England
May 2025
P-003706 — Norfolk and Norwich University Hospitals NHS Foundation Trust
Mr L complained the Trust left him without essential eye drops for eight weeks due to errors and failed to advise him on stopping medication as an inpatient, causing stress.
NHS in England
Jul 2025
P-003751 — East Kent Hospitals University NHS Foundation Trust
Mrs S complained about delays in her husband's feeding, cancelled tests, and inappropriate discharges. She also alleged antidepressants were stopped for two weeks, causing severe depression.
NHS in England
Aug 2025
P-003914 — Maidstone and Tunbridge Wells NHS Trust
Mrs U alleged the Trust caused her husband's death by an overload of IV fluids, rather than pneumonia as stated on his death certificate.
NHS in England
Sep 2025
P-004244 — Dartford and Gravesham NHS Trust
Mr D complained the Trust administered a medication on 9 September that led to his mother’s sudden death, causing his father and him immense distress.
NHS in England
Oct 2025
P-004162 — Wirral University Teaching Hospital NHS Foundation Trust
Mr A complained the Trust gave his wife an antibiotic without informing him, left her on a trolley too long, didn't assist her mobilisation, and provided inappropriate nutrition.
NHS in England
Partly 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-004453 — King's College Hospital NHS Foundation Trust
Miss P complained the Trust inappropriately prescribed adenosine during her father's procedure, causing a respiratory reaction, intubation, and his eventual death, without considering his medical history.
NHS in England
Dec 2025
P-004514 — A practice in the Gateshead area
Mrs G complained the Practice failed to reissue her morphine medication at the correct dosage and a receptionist prevented her from discussing suicidal feelings, leading to withdrawal symptoms and hospital admission.
NHS in England
Dec 2025
P-001063 — East Kent Hospitals University NHS Foundation Trust
Miss A complained her father received inadequate nutrition, Parkinson's medication, physiotherapy, and pressure sore management, experiencing poor care and staff rudeness.
NHS in England
Upheld
Apr 2021
P-001070 — The Dudley Group NHS Foundation Trust
Mrs M complained there was a delay in diagnosing her father’s stroke and that morphine administration made subsequent assessment difficult, leading to a significant decline in his health.
NHS in England
Partly Upheld
May 2021
LGO / SPSO decisions(9)
PSOW-202005941 — Cwm Taf Morgannwg University Health Board
Mrs A complained that a GP Practice in the area of Cwm Taf Morgannwg University Health Board failed to arrange a timely referral to secondary care for her late mother, Mrs G, between 20 January and 18 March 2020 in relation to increasingly painful symptoms in her lower left leg. …
PSOW (Public Services Om…
Health
Upheld
Aug 2021
PSOW-202101243 — Cardiff and Vale University Health Board
Mr X complained that the Health Board had failed to prescribe him a newly approved medication called Fampridine, a drug used to improve walking ability in patients with multiple sclerosis. Mr X said this resulted in him paying for private prescriptions when he should have received the treatment from the …
PSOW (Public Services Om…
Health
Sep 2021
PSOW-202400150 — A GP Practice in the area of Cardiff …
Ms W complained that the Surgery had failed to respond to her complaint about her husband’s missing prescription. The Ombudsman decided that there had been a failure by the Surgery to respond to the complaint and this had caused frustration and uncertainty for Ms W. The Ombudsman decided to settle …
PSOW (Public Services Om…
Health
May 2024
NIPSO-202000068 — Belfast Health and Social Care Trust
We found the Belfast Trust was right to encourage a patient with cystic fibrosis to persevere with its chosen course of treatment, but criticised a lack of community dietetic support which left her at potential risk of harm.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Apr 2024
PSOW-202306591 — Aneurin Bevan University Health Board
Ms A complained about the care and treatment her mother received when in hospital. The Ombudsman found that the complaint response provided by the Health Board had not fully considered all aspects of Ms A’s concerns in line with relevant complaints guidance. Ms A had also indicated that she would …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202504068 — Swansea Bay University Health Board
Miss A complained that the Health Board prescribed and administered the incorrect dose of epilepsy medication to her 3-year old daughter when she attended the Emergency Department. Miss A said that despite having evidence of the prescribed medication, the Health Board said that there was no record of a prescription …
PSOW (Public Services Om…
Health
Oct 2025
PSOW-202201099 — Cardiff and Vale University Health Board
Mr X complained that the Health Board had failed to prescribe him a newly approved medication called Fampridine, a drug used to improve walking ability in patients with multiple sclerosis. Mr X said this resulted in him paying for private prescriptions when he should have received the treatment from the …
PSOW (Public Services Om…
Health
Jul 2022
21-003-612a — Livewell Southwest (21 003 612a)
Summary: Ms X complains about a lack of care and support provided to her late sister, Ms Y. Ms X says this enabled Ms Y to ingest items she should not have had access to, and that a serious incident report did not answer some of her questions about what …
LGO (Local Government & …
Health
Upheld
Jun 2022
PSOW-202106456 — Cardiff and Vale University Health Board
Mrs X complained about the Health Board’s management of her chronic pain over the last year and about the unresolved issue of arranging a regular prescription of Lidocaine patches which has caused her pain and impacted on the quality of her life. Mrs X had complained to the Health Board …
PSOW (Public Services Om…
Health
Feb 2022