Pharmacist missed drug contraindications
Community pharmacists failing to identify critical drug contraindications due to confusion over clinical check duties.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PPO recommendation
73match
The Head of Healthcare, lead GP and lead pharmacist at HMP Wandsworth
The Head of Healthcare, lead GP and lead pharmacist should review the ‘homely remedies’ protocol to ensure that it makes reference to checking a prisoner’s prescribed medication to ensure no contraindications before the provision of a ‘homely remedy’.
Matched on
terms: contraindication, pharmacist
PFD report
69match
Wayne O’Neill
The coroner noted a lack of recognition among clinicians regarding a specific medication's contraindication for asthma and the risks associated with a combination of psychotropic drugs. Concerns were also raised about the absence of routine ECG screening for prisoners prescribed this medication combination.
Matched on
terms: contraindication, drug
Inquiry recommendation
69match
IHRD-25 - Drug Prescription Documentation
All instances of drug prescription and administration should be entered into the main clinical notes and paediatric pharmacists should monitor, query and, if necessary, correct prescriptions. In the event of correction the pharmacist should inform the prescribing clinician.
Matched on
terms: drug, pharmacist
PFD report
65match
Sneh Chaudhry
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.
Matched on
terms: drug
Committee recommendation
62match
#26 - English pharmacists twice as likely to prescribe antibiotics for sore throats than Welsh counterparts.
Under the Pharmacy First scheme introduced in early 2024, patients can now consult pharmacists directly for several minor illnesses and conditions that previously required a GP visit and the pharmacist can prescribe medicines if necessary. NHS England commented that early evidence from Pharmacy First was that GPs were following the relevant protocols, and it had not seen any...
Matched on
terms: pharmacist
PFD report
61match
Michael Anthony
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.
Matched on
terms: drug
PFD report
61match
Jennifer Lacey
The coroner noted concerns regarding the free online availability of dangerous and addictive drugs, which can be prescribed without contact with a patient's regular doctor or access to their medical records, and potentially filled in UK pharmacies without further checks.
Matched on
terms: drug
PFD report
57match
Carol Ann Gibson
The coroner highlighted concerns about 'alert fatigue' within a medical practice, where a doctor prescribed a drug despite an adverse reaction alert. The report notes potential issues with the alert system, clarity of alerts, and staff training.
Matched on
terms: drug
PFD report
57match
Bertram Hamilton
The coroner raised concerns about a nurse's apparent lack of knowledge regarding the contraindication of administering insulin to a person with very low blood sugar levels.
Matched on
terms: contraindication
PFD report
57match
Teresa Lonergan
The general practice did not monitor the patient's consumption of controlled drug prescriptions, leading to a significant accumulation of medication. This situation was exacerbated as the care worker administering the drugs did not report medical instructions.
Matched on
terms: drug
PFD report
57match
Kerry Jacobs
The coroner noted a lack of documentation for steroid prescriptions outside usual guidelines and insufficient communication with the consultant. There was also no protocol for pharmacists to discuss queried dosages with clinicians.
Matched on
terms: pharmacist
PFD report
57match
Dafydd Watts
The coroner noted that the possibility of a rare drug occurrence is not highlighted to physicians in drug literature or in the BNF entry.
Matched on
terms: drug
PFD report
57match
Andre Mickley
The coroner noted that official drug information (SPC/PIL) lacks guidance for prescribers to inquire about a history of substance misuse and for patients to be cautious about potential adverse interactions between prescribed medicines and drugs of misuse. This gap applies to interactions beyond just SSRIs and cocaine.
Matched on
terms: drug
PFD report
57match
Patricia Thomas
The coroner noted a potential drug interaction between Miconazole Gel and Warfarin, which can increase bleeding risk. There is a lack of awareness of this interaction among health professionals and difficulty in locating clear information.
Matched on
terms: drug
PFD report
57match
Kinga Cieciorska
The coroner identified a missed opportunity to investigate abnormal ECG and tachycardia, alongside failures in recording and transmitting medical information, and a lack of consideration for the significance of Diclofenac medication.
Matched on
terms: missed
PFD report
57match
Stuart Walls
The coroner noted insufficient consideration of the totality of prescribed medications and their potential synergistic effects, particularly for drugs affecting the central nervous system and respiration, which combined to cause a drug poisoning death.
Matched on
terms: drug
PFD report
57match
Paul Mullen
The coroner raises concerns about the 'red flag system' for reporting uncollected methadone prescriptions, noting that reports were routed indirectly through GMMH instead of directly to the patient's Key Worker at Addaction, causing delays. This system did not allow for earlier reporting for diligent patients who missed a single dose.
Matched on
terms: missed
PFD report
57match
Deborah Chapman
The coroner identified gaps in the medical centre's inquiry and recording of a patient's illicit drug misuse, which prevented an informed risk assessment for prescribing pregabalin and oxycodone given potential interactions.
Matched on
terms: drug
PFD report
57match
Mary Nelson
The coroner raised concerns about Fluoxetine accumulating to dangerous levels that could trigger cardiac rhythm disturbance, questioning if dosage guidance needs revision or in-life drug level testing. Additionally, the death was not reported via the Yellow Card system.
Matched on
terms: drug
PFD report
53match
Gabriele Kreichgauer
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.
Matched on
classifier match
PFD report
49match
Nicos Michael
Inconsistent and incomplete documentation of the patient's allergies across multiple hospital records meant this critical information was not consistently available to staff or shared with the GP. Current medical reporting and computer systems do not adequately ensure allergy information is readily accessible for patient treatment.
Matched on
classifier match
PFD report
49match
Jessica Bond
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.
Matched on
classifier match
PFD report
49match
Christopher Davies
The coroner noted insufficient information shared with the patient and family about clozapine interactions with caffeine or smoking cessation, and the warning signs of toxicity. Regular reminders were suggested due to memory issues.
Matched on
classifier match
PFD report
49match
Mary Bloom
The coroner identified non-compliance with Trust policy for heparin administration, specifically regarding weighing the patient, consulting haematology for low weight, and re-attempting baseline bloods. Critical information for underweight patients on the heparin poster was also not sufficiently visible.
Matched on
classifier match
PFD report
49match
Paul Ryley
The coroner noted that Toxbase guidelines for paracetamol overdose do not clearly state steps for patients re-presenting within a short time of initial attendance. This leads to clinicians commonly misunderstanding their applicability, risking patients not receiving necessary treatment.
Matched on
classifier match
PFD report
49match
Chand Ali
Cyclizine is routinely administered to heart failure patients without individual risk assessment, and there is no system to balance its risks against clinical need. The hospital does not monitor deaths following its use or review alternative antiemetics.
Matched on
classifier match
PPO recommendation
48match
The Head of Healthcare, the lead GP and the senior pharmacist at HMP Wandsworth
The Head of Healthcare, the lead GP and the senior pharmacist should review the glyceryl trinitrate and aspirin PGDs to ensure that staff are able to use these emergency medications in all situations where they are indicated and ensure that the inclusion criteria takes account of the additional presentation of a cardiac event without pain in diabetic patients.
Matched on
terms: pharmacist
IMB recommendation
48match
Cardiff (2025)
How will the Health Board ensure that prescribing checks at HMP Cardiff are resolved quickly, given that the pharmacists’ job-sharing arrangement prevents in-prison checks?
Matched on
terms: pharmacist
PFD report
45match
John Michael Bailey
The coroner noted an absence of clear protocol guidance and a robust system for primary care physicians managing Amiodarone, along with inconsistent Shared Care Protocols across different Trusts, which could pose risks to patients and transferring staff.
Matched on
classifier match
PFD report
45match
Tripta Rani Kumar
The patient's medical notes were altered, removing a documented penicillin allergy without signature or verification, which led to a penicillin-containing antibiotic being prescribed and posed a risk of anaphylactic shock.
Matched on
classifier match
PFD report
45match
Joseph Godfrey
The coroner identified insufficient awareness among care staff and paramedics regarding the increased bleeding risk for elderly patients on warfarin after a head injury. Concerns were also raised about care home staff not following observation instructions, inadequate record-keeping, and the need for improved training on falls prevention and anticoagulants.
Matched on
classifier match
PFD report
45match
Akua Anokye-Boateng
The coroner noted a lack of clear best practice guidance regarding the use of gastro-intestinal protection when prescribing NSAIDs to children with sickle cell disease, despite expert evidence of perforation risk.
Matched on
classifier match
PFD report
45match
Lisa Webb
The coroner raised concerns about a general practitioner's suboptimal asthma management, citing insufficient respiratory assessment and monitoring. Additionally, the prescription of Diazepam for anxiety was noted as poor treatment, especially with sleep apnoea or respiratory distress.
Matched on
classifier match
PFD report
45match
John Day
The coroner raised concerns that out-of-hours doctors do not have access to the "Allergies" section of patient medical notes, hindering their ability to verify medication appropriateness, especially when patients provide incorrect information or lack capacity.
Matched on
classifier match
PFD report
45match
Beryl Walters
The coroner raised concerns regarding the use of Cyclizine in patients with severe heart failure, noting cautions in the British National Formulary and the availability of an alternative antiemetic with a different cardiac risk profile.
Matched on
classifier match
PFD report
45match
Marjorie Ellery
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.
Matched on
classifier match
PFD report
45match
Isaac Bahar
The coroner noted that Mr. Bahar, a patient with Stage 4 Chronic Kidney Disease, was inappropriately prescribed and given Codeine, which was a breach of both hospital policy and national guidance and led to severe opiate toxicity.
Matched on
classifier match
PFD report
45match
Lynn Poyser
The coroner raised concerns regarding whether current guidance on co-prescribing ACE inhibitors and Spironolactone sufficiently emphasizes the need for caution, patient monitoring, and a holistic approach, given known risks such as hyperkalaemia.
Matched on
classifier match
PFD report
45match
Dorothy Delaney
The coroner noted Alexander House Health Centre's practice of prescribing concurrent antiplatelet and anticoagulant medications without seeking individual specialist advice, instead relying on general advice for other patients.
Matched on
classifier match
PFD report
45match
Irene Pearson
The coroner raised concerns about the clarity of Matrifen leaflet warnings regarding hot baths and Macmillan Nurses' advice on patch removal. There were also identified gaps in liaison between Macmillan Nurses and the GP practice, alongside unclear GP patient notes.
Matched on
classifier match
PFD report
45match
Peter Rowe
A penicillin-based antibiotic was prescribed and administered despite a GP referral letter stating a penicillin allergy. Concerns were raised about the deletion of allergy information from the patient's record and the insufficient verification of allergy status, particularly given the patient's cognitive impairment.
Matched on
classifier match
PFD report
45match
Edward Mallen
The coroner noted concerns that a GP prescribed medication based on advice from a non-prescribing nurse, resulting in the patient not receiving crucial information about potential increased suicidality or crisis support. There was also a reported lack of awareness among GPs regarding the duty psychiatrist service.
Matched on
classifier match
PFD report
45match
Richard Breatnach
The coroner identified gaps in the online prescribing process, including applications allowing false information without prescriber verification with GPs, and the inappropriate prescribing of excessive dihydrocodeine without direct patient assessment.
Matched on
classifier match
PFD report
45match
Charles Rendell
The coroner raised concerns that the potential side effect of Ciprofloxacin, which can cause depression or psychosis leading to suicidal ideation, is not clearly communicated to patients or sufficiently emphasized to prescribing clinicians.
Matched on
classifier match
PFD report
45match
Theresa Thompson
The coroner noted that Mrs Thompson, a post-splenectomy patient, was not receiving lifelong antibiotic prophylaxis or specific vaccination, particularly around a recent surgical procedure. Concerns were also raised regarding the clarity of advice from health agencies about the importance of antibiotic prophylaxis.
Matched on
classifier match
PFD report
45match
Claire Medhurst
The discharge process did not include cautionary advice on analgesic use, and treating clinicians did not receive alerts from the haematology laboratory for abnormal ALT and toxic paracetamol levels.
Matched on
classifier match
PFD report
45match
Pauline Pryor
The coroner noted insufficient communication between the nursing home and GP surgery, leading to a lack of required lithium blood tests. Additionally, a consultant's advice on medication reduction was not seen by the GP.
Matched on
classifier match
PFD report
45match
Theresa Feehan
The coroner identified inadequacies in the practice's medication review system, including the recording of active problems and the correlation between medication and problem lists. Concerns were also raised regarding the identification of medication interactions and the need to audit administrative systems.
Matched on
classifier match
PFD report
45match
Mohammed Ahmed
The coroner noted expert evidence suggesting a combination of Olanzapine and Spice could cause adverse allergic reactions, and raised concerns about whether this potential interaction is sufficiently known to clinicians nationally.
Matched on
classifier match
PFD report
45match
Christopher Summerhayes
The coroner raised concerns regarding the prescription of Clozapine alongside numerous other medications, leading to significant weight gain and potential cardiovascular issues, and the lack of consideration for familial lipid disorders that might contraindicate its use.
Matched on
classifier match