Pharmacist missed drug contraindications
Community pharmacists failing to identify critical drug contraindications due to confusion over clinical check duties.
Source spread
Where this theme appears
This theme appears across 9 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
108 PFD reports
4 committee recs
6 HSSIB recs
2 CQC actions
2 PPO recs
7 IMB recs
52 PHSO decisions
13 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(108)— showing 50 strongest matches
John Michael Bailey
Concerns: The coroner notes an absence of clear protocol guidance for primary care physicians.
Overdue
Carol Ann Gibson
Concerns: A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety warnings within the medical practice.
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
Bertram Hamilton
Concerns: The coroner was concerned that a nurse appeared not to know that insulin should not be given to a person whose blood sugars were so low.
Overdue
Teresa Lonergan
Concerns: The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal overdose.
Overdue
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
Joseph Godfrey
Concerns: Care staff and paramedics lacked awareness of warfarin-related bleeding risks in elderly fall patients. Care home staff failed to follow observation protocols, document checks, or access medical history, and BUPA's investigation was insufficient.
Overdue
Michael Anthony
Concerns: The coroner noted that the deceased's Gabapentin level was five times the normal therapeutic level, the reason for which was undetermined, and that the drug is usually not prescribed in diabetics due to the risk of severe reaction.
Response (Guys St Thomas NHS Trust): The trust has built a review of the case into their day to day practice and reported the case via the MHRA yellow card reporting system. The trust has also …
Overdue
Nicos Michael
Concerns: The coroner identified conflicting evidence regarding the deceased's recorded allergies, noting a lack of readily available and continuously updated allergy information for hospital staff, and that electronic prescribing was not compulsory.
Response (East Kent Hospitals University): East Kent Hospitals University NHS Foundation Trust notes the coroner's concerns regarding the recording of a reported allergy to penicillin throughout the healthcare records, but states that concerns are based …
Responded
Dafydd Watts
Concerns: Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences associated with medication.
Overdue
Akua Anokye-Boateng
Concerns: The report raises concerns about the use of NSAIDs in children with sickle cell disease, specifically regarding the potential for a single dose to cause GI damage and the lack of clear guidance on gastro-intestinal protection measures.
Response (Medicine Healthcare Products Regulatory Agency): The MHRA will publish an article in the September 2014 Drug Safety Update to remind healthcare professionals of existing SPC information regarding GI side-effects of NSAIDs. They will also strengthen …
Responded
Lisa Webb
Concerns: Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective measurements (peak flow/oximetry), and an inappropriate Diazepam prescription.
Response (Basildon Road Surgery): The GP now ensures that during consultations with significant problems, they check past reviews and previous consultations. They also check to see if any reviews are outstanding, and either complete …
Overdue
John Day
Concerns: Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication prescriptions when patients provide inaccurate details or lack capacity.
Response (Isle of Wight Clinical Commissioning Group): The Isle of Wight CCG is developing a system-wide IT strategy to move towards a universal, integrated, and readily accessible healthcare record, but notes there is still a long way …
Response (Beacon Health Centre): A reminder was sent to all out of hours GPs to consider trying to access Vision 360 if clinically indicated, and the Beacon out of hours service is working closely …
Responded
Jessica Bond
Concerns: Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine rupture and associated complications.
Overdue
Christopher Davies
Concerns: Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning signs of toxicity.
Overdue
Beryl Walters
Concerns: Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative being available, posing avoidable patient harm.
Overdue
Marjorie Ellery
Concerns: Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent obtained for this treatment was not informed consent.
Response (Frimley Health NHS Trust): The Trust now requires registrar or higher authorisation and documented discussion with the patient for medication prescriptions when allergies are known. A new policy on allergy management is being developed …
Responded
Isaac Bahar
Concerns: A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on medication for vulnerable patients.
Response (Brighton and Sussex University Hospitals Trust): Brighton and Sussex University Hospitals Trust has discussed the incident with general surgeons and the nursing and pharmacy teams, leading the general surgeons to decide that codeine should no longer …
Responded
Andre Mickley
Concerns: Product information for SSRI drugs fails to adequately inform prescribers about potential adverse pharmacokinetic interactions with cocaine and other illicit substances, or to advise patients to seek caution.
Overdue
Lynn Poyser
Concerns: Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for more caution and a holistic patient view.
Overdue
Dorothy Delaney
Concerns: The concurrent prescription of antiplatelet and anticoagulant medications without specialist advice contradicted national guidelines, significantly increasing haemorrhage risk, especially given the patient's amyloid angiopathy.
Overdue
Wayne O’Neill
Concerns: There was inadequate recognition of drug contraindications and dangerous psychotropic medication combinations, with no routine ECG monitoring performed despite expert recommendations, leading to significant risks.
Response: All patients prescribed anti-psychotic medication will receive a routine annual ECG as part of their care; the Lead Pharmacist will sample audit this by 31 January 2016. Training will be …
Responded
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
Irene Pearson
Concerns: Matrifen patch warnings about hot baths are obscure and vague, and dangerous advice was given to use baths for patch removal. Poor liaison on opiate prescribing and unclear, scanty GP electronic notes contributed to unsafe care.
Response (I Pearson): Takeda has reported the coroner's concerns about heat exposure and fentanyl patches to Johnson and Johnson and requested they conduct a review to determine if changes to product information are …
Response (I Pearson Response2): Following the inquest, the Macmillan team sent a 'Trust Alert' out to all hospital and community staff reminding them not to advise patients to take a bath to aid removal …
Overdue
Patricia Thomas
Concerns: A significant lack of awareness among health professionals regarding the dangerous interaction between Miconazole Gel and Warfarin, combined with unclear information resources, risks uncontrolled bleeding.
Overdue
Kinga Cieciorska
Concerns: A missed opportunity to investigate abnormal ECG trace and tachycardia; systemic failings in recording and transmission of information, with GP medical notes not seen by the Junior Doctor; details of medication including the significance of the drug, Diclofenac, was not considered.
Overdue
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
Edward Mallen
Concerns: A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical side effects or support contacts. GPs also lacked awareness of available psychiatrist consultation.
Overdue
Richard Breatnach
Concerns: Online medication prescribing allowed applicants to provide false information without verification, leading to excessive and inappropriate prescription of an addictive drug without patient contact or correct guidance.
Response (NHS England): NHS England will assimilate current regulatory and professional guidance into one place for online prescribing, and will use this learning to inform its Digital Strategy. They will also include advice …
Overdue
Charles Rendell
Concerns: There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal ideation. This lack of awareness prevents timely recognition and appropriate reaction to potential symptoms.
Response (Bayer PLC): Bayer states that patient safety is taken very seriously. They reviewed reports of psychiatric effects associated with ciprofloxacin and believe the UK product information includes an appropriate warning to advise …
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA reviewed the information and considers that the product information for Ciproxin provides up-to-date information on the risk of mental disturbances. They will review all UK Package Leaflets for …
Responded
Theresa Thompson
Concerns: A post-splenectomy patient died from Streptococcus pneumonia due to lack of lifelong antibiotic prophylaxis and vaccination. Mixed messages about antibiotic use may deter patients from accepting crucial preventative treatments.
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
Stuart Walls
Concerns: The patient died from a synergistic toxic effect of multiple prescribed drugs, each within therapeutic range, affecting the central nervous system and respiration. Prescribing practices need to account for cumulative drug interactions.
Overdue
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
Pauline Pryor
Concerns: Critical communication failures between the nursing home and GP, an inadequate system for monitoring lithium toxicity, and an unread consultant email led to missed essential blood tests and unmanaged medication changes.
Response (NHS England): NHS England will raise the need for formal communication between agencies regarding patients with mental health issues in their GP bulletin and provide information to the LMC for distribution. They …
Responded
Sneh Chaudhry
Concerns: Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a risk of administering the wrong, more toxic medication.
Overdue
Paul Ryley
Concerns: Unclear Toxbase guidelines for paracetamol overdose re-presentations lead clinicians to misunderstand their applicability, risking patients not receiving crucial treatment for liver toxicity.
Response (NPIS Clinical Standards Group): The NPIS has added a statement to the paracetamol index in TOXBASE guidance: "If the patient re-presents following assessment and discharge, manage as per a new presentation."
Responded
Jennifer Lacey
Concerns: Concerns were raised about dangerous, addictive drugs being freely available online and prescribed by foreign doctors without patient contact or GP record access, potentially filled by UK pharmacies without adequate checks.
Response (NHS England): NHS England acknowledges concerns about online availability of potentially dangerous drugs like Tramadol, but states that the death was not a result of NHS services. They are working with other …
Overdue
Theresa Feehan
Concerns: The practice's medication review system was inadequate, with outdated patient records and poor correlation between problem lists and prescribed drugs. This led to dangerous medications being continued and a lack of proper rationale for prescribing.
Response (CQC): The CQC conducted inspections of Lisson Grove Health Centre but ultimately did not find concerns in the areas identified in the prevention of future death report. They rated the health …
Overdue
Gabriele Kreichgauer
Concerns: The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource led to ineffective treatment. The resource also lacked a clinician feedback mechanism for inaccuracies.
Overdue
Chand Ali
Concerns: Cyclizine, cautioned for severe heart failure, is routinely administered without individual risk assessment or monitoring of adverse outcomes. There has been no review of alternative antiemetics.
Response (Barts Health NHS Trust): The Trust reviewed the evidence for the caution in the British National Formulary regarding cyclizine use in heart failure patients and found the evidence limited. They will warn teams of …
Responded
Mohammed Ahmed
Concerns: Combined use of Olanzapine and Spice caused a fatal allergic reaction, yet Olanzapine continued to be prescribed. Clinicians may lack national awareness of serious drug interactions and side effects with Olanzapine.
Response (Department of Health): The Department of Health acknowledges the concerns but states that the MHRA considers current warnings for olanzapine to be adequate and will keep the issue under scrutiny. NHS England will …
Overdue
Christopher Summerhayes
Concerns: Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible contraindicating familial lipid disorder was not confirmed.
Response: The Health Board reported the death to the Medicines and Healthcare products Regulatory Agency (MHRA). A project proposal is in development by the Mental Health Clinical Board, Pharmacy and Information …
Responded
Deborah Chapman
Concerns: Medical records failed to show adequate inquiry into illicit drug misuse, preventing informed risk assessments for prescribing medications with known respiratory side effects, and lacked a system for recording such information.
Response (West Timperley Medical Centre): The medical centre has implemented a regular search of the clinical system to identify patients taking regular opiate analgesia or Pregabalin with a past history of drug misuse and are …
Responded
Graham Saffery
Concerns: The BNF, a key GP resource, lacks warnings for co-prescribing amitriptyline and oxycodone, despite other guidance recommending caution and monitoring for this interaction.
Response (Bedfordshire CCG): The CCG has shared learning from the incident with other practices and the East of England NHS England, developed a SystmOne search to identify at-risk patients, briefed prescribing leads, and …
Responded
Graham Earl
Concerns: GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and were unaware of side effect escalation procedures.
Overdue
Abdeslam Benelghazi
Concerns: Concurrent prescribing of methadone with multiple sedative medications, particularly clonazepam, created a dangerous combined effect of central nervous system and respiratory depression, significantly increasing the risk of sudden death.
Response (Department of Health and Social Care): The Department of Health and Social Care plans to publish a White Paper in early 2020 responding to the Independent Review of the Mental Health Act and will consult publicly …
Responded
Katherine Stamp
Concerns: The serious side effects of clozapine, particularly regarding smoking and pneumonia, are under-appreciated by prescribers and not sufficiently detailed in national guidance.
Overdue
Mary Nelson
Concerns: Dangerous fluoxetine accumulation suggests a need to revise dosage guidance, especially for the elderly, and consider in-life drug testing. This death was also not reported to the Yellow Card system.
Overdue
Shanté Turay-Thomas
Concerns: GPs failed to ensure specialist allergy care, provided inadequate advice on carrying two adrenaline pens, and did not offer training for new auto-injector devices, compounded by deficient CCG guidance on dosage.
Response (NHS England): NHS England will continue to work with HEE, the professional Royal Colleges, and other organizations to stay updated on new guidance and resources for managing severe allergies, and will explore …
Response (Advanced): Advanced states they will work with NHS Digital to develop a standard for electronic updating of ambulance systems to inform them when an ambulance has been recalled. They also suggest …
Response (National Institute for Health and Care Excellence): NICE notes that the British National Formulary (BNF) and BNF for Children (BNFc) already contain detailed advice on adrenaline auto-injectors, including MHRA/CHM advice from 2017 and 2019. It will consider …
Response (Bausch Lomb): Bausch & Lomb distributes trainer pens to allergy clinics and is currently reviewing the design of its trainer pens to incorporate a needle cover shield extension when activated, to more …
Response (Radcliffes Le Brasseur): The Winchmore Hill Practice undertook an audit of patients prescribed Emerade to ensure dosage was in accordance with the BNF, reviewed AAI pen doses, and contacted patients with up-to-date advice …
Response (NHS England): NHS Digital details changes made to NHS Pathways following the incident, including improving the Anaphylaxis algorithm, developing an audit framework, and conducting a user satisfaction survey to improve call-handling and …
Response (London Ambulance Service): LAS clarifies the division of responsibilities for triage systems, stating that ECPAG and NHS Digital are responsible for setting categories and addressing inconsistencies between systems. LAS will discuss the PFD …
Response (Department of Health and Social Care): The Department of Health and Social Care notes several actions, including the FSA working to get emerging trend information and alert local authorities, and working to identify means of access …
Response (Enfield CCG): Enfield CCG distributed a Medicines Safety Bulletin on Adrenaline Auto Injectors (AAIs) to GPs and other primary care healthcare professionals on 30th January 2020 and has contacted all GP practices. …
Responded
Select committee recommendations(4)
#26 — English pharmacists twice as likely to prescribe antibiotics for sore throats than Welsh counterparts.
Recommendation: 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 …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2027 4.2 The government is working to fulfil Outcome 6 of the NAP, which commits to cross-sector working to develop diagnostics as a …
Accepted
#21 — A significant proportion of antibiotic prescriptions in primary care are inappropriate.
Recommendation: Misuse and overuse of antimicrobials in humans can occur when they are prescribed inappropriately. Inappropriate use is when antimicrobials are prescribed when they are unnecessary (such as using antibiotics, which are only effective against bacteria, to treat a viral infection), …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2027 4.2 The government is working to fulfil Outcome 6 of the NAP, which commits to cross- sector working to develop diagnostics as …
Accepted
#22 — Inadequate diagnostic tests hinder clinicians from reducing inappropriate antimicrobial prescribing effectively.
Recommendation: Better use of diagnostic tools can reduce inappropriate prescribing.56 Diagnostic tools are those which can help diagnose what infection a patient has, thereby helping clinicians determine with accuracy whether a patient needs an antimicrobial treatment and, if so, which one.57 …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2027 4.2 The government is working to fulfil Outcome 6 of the NAP, which commits to cross- sector working to develop diagnostics as …
Accepted
#4 — Mandate health bodies to demonstrate progress in using diagnostic tools for AMR over two years.
Recommendation: DHSC has made slow progress in implementing diagnostic tools that could help reduce AMR. Inappropriate prescribing of antibiotics in primary care is estimated to be around 20% of antibiotic prescriptions, which is too high and could drive AMR. ‘Inappropriate’ includes …
Gov response: The government agrees with the Committee’s recommendation. sector working to develop diagnostics as a tool to tackle AMR. DHSC, through National Institute for Health and Care Research (NIHR), has invested over £18 million into research …
Accepted
HSSIB safety recommendations(6)
Potential under-recognised risk of harm from the use of propranolol
Safety action by the Medicines and Healthcare products Regulation Agency (MHRA) The MHRA is reviewing the information in the Summary of Product Characteristics (a legally required document detailing a medicine’s properties and officially approved conditions of use) for propranolol-containing products …
Safety Action
Potential under-recognised risk of harm from the use of propranolol
Further research into possible interactions between propranolol and Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants in overdose would be beneficial.
Safety Observation
Potential under-recognised risk of harm from the use of propranolol
Electronic prescribing systems used in primary care may benefit from alerts that prompt clinicians about the potential risks of prescribing propranolol to people in certain patient groups.
Safety Observation
Medication not given: administration of time critical medication in the emergency department
What pharmacy support is available to staff in ED to support in the care of patients who need time critical medications?
Learning Prompt
Procurement, usability and adoption of ‘smart’ infusion pumps
British National Formulary
Learning Prompt
Potential under-recognised risk of harm from the use of propranolol
It is recommended that the Royal Pharmaceutical Society supports its members in identifying the potential risk of prescribing propranolol to patients in at-risk groups.
Safety Recommendation
CQC inspection actions(2)
The Withins
No checks had been made to make sure it was safe for people to take these medicines and to ensure they would not interact with people's prescribed medicines.
Should Do
Melville House
We advised the manager to seek the advice of the pharmacist in sourcing means to deal with the cause of the odour.
Should Do
PPO death in custody recommendations(2)
The Head of Healthcare, lead GP and lead pharmacist at …
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’.
The Head of Healthcare, the lead GP and the senior …
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 …
IMB individual recommendations(7)
Cardiff IMB (2025)
Sut bydd y Bwrdd Iechyd yn sicrhau bod archwiliadau presgripsiynu yng Ngharchar Caerdydd yn cael eu datrys yn gyflym, o ystyried bod trefniant rhannu swydd y fferyllwyr yn atal archwiliadau yn y carchar?
NHS / Healthcare Provider
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?
NHS / Healthcare Provider
Implemented
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
Lancaster Farms (2025)
When will the Prison Service work with service providers to ensure anomalies in provision of medication are addressed?
HMPPS
In Progress
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
Cardiff (2021)
The Board has two concerns in relation to healthcare which we would ask the Health Minister to consider with Cardiff and the Vale Health Board. Both relate to staffing: the first is the ongoing issue with lack of cover for pharmacists, which can lead to locum pharmacists being brought in on an emergency basis and affects the planning of the …
NHS / Healthcare Provider
In Progress
PHSO casework decisions(52)
P-001278 — A medical practice in the Norfolk area
Mr Y complained the Practice incorrectly prescribed allopurinol during an acute gout attack, contrary to guidelines. He stated this delayed his recovery and caused significant, prolonged pain.
NHS in England
Partly Upheld
Jan 2022
P-001336 — A medical practice in the Surrey area
Miss A complained that a GP failed to restart her father's diabetic and blood-thinning medications and incorrectly stopped another, leading to a severe decline in his health.
NHS in England
Partly Upheld
Mar 2022
P-003554 — A practice in the Ealing area
Mrs P complained a Practice prescribed her late husband amoxycillin despite a known penicillin allergy, resulting in a severe, body-wide rash and prolonged discomfort.
NHS in England
May 2025
P-001282 — Northumbria Healthcare NHS Foundation Trust
Mr A complained the Practice prescribed his wife an antibiotic she had a previous adverse reaction to, causing severe illness and death, and the Trust transferred her too quickly.
NHS in England
Partly Upheld
Jan 2022
P-001436 — North Tees and Hartlepool NHS Foundation Trust
Mrs L complained the Trust misdiagnosed her stroke as a migraine, prescribed inappropriate medication (Sumatriptan), and failed to consider alternative medication, leading to health deterioration and distress.
NHS in England
Jun 2022
P-001731 — Imperial College Healthcare NHS Trust
Mrs A complained the Trust prescribed her incorrect medication (amlodipine, amiodarone) after gall bladder surgery, causing her to be extremely ill and prolonging her hospital stay.
NHS in England
Jan 2023
P-001825 — A practice in the Cheshire area
Mrs G complained the Practice stopped her mother's blood-thinning medication without a physical examination and gave an unsatisfactory explanation for the decision.
NHS in England
Feb 2023
P-001878 — The Newcastle Upon Tyne Hospitals NHS Foundation Trust
Mrs B complained the Trust did not recommend a stomach-lining medication with her anti-inflammatory drugs, causing an ulcer. She also alleged delayed treatment for her arthritis.
NHS in England
Mar 2023
P-002037 — East London NHS Foundation Trust
Dr L complained a Trust doctor failed to identify correct medication/dosage, discuss alternatives, explain side effects, or approve external requests, leading to numerous hospital admissions.
NHS in England
Jun 2023
P-003865 — Portsmouth Primary Care Alliance Ltd
Miss G complained the Practice and PPCA failed to correctly test for and treat her grandfather's urinary tract infection, leading to his death.
NHS in England
Jul 2023
P-003845 — Salford Royal NHS Foundation Trust
Miss U complained the Trust continued prescribing a strong cream for her skin condition despite side effect concerns, causing her to develop multiple serious health problems.
NHS in England
Sep 2023
P-002268 — A practice in the Warrington area
Miss U alleged her GP failed to consider her medical history when prescribing medication, did not inform her of potential side effects, and delayed diagnosing an allergic reaction.
NHS in England
Oct 2023
P-002336 — A practice in the Suffolk area
Mr I complained the Practice prescribed him an excessive dose of simvastatin with amlodipine for a decade. He alleged this risky dose was never identified during his annual medication reviews.
NHS in England
Dec 2023
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-002814 — A dental practice in the City of Brighton …
Ms A complained the dental practice failed to investigate her sensitive teeth at multiple examinations and inappropriately prescribed antibiotics, causing pain, abscesses, and tooth loss.
NHS in England
Partly Upheld
Jul 2024
P-003140 — Sussex Partnership NHS Foundation Trust
The Trust allegedly failed to exercise due care prescribing sertraline to Mr N, did not respond to behaviour changes, and lacked appropriate monitoring.
NHS in England
Nov 2024
P-004054 — A dental practice in the City of Wolverhampton …
Mr X (represented by Mrs X) complained a dental practice extracted four teeth without consulting his main carer (his wife) and despite him taking apixaban, causing eating difficulties and increased anaemia medication.
NHS in England
Sep 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-001827 — Liverpool University Hospitals NHS Foundation Trust
Ms A complained the Trust prescribed medication to her mother without explaining risks, failed to order a fibroscan, and didn't communicate abnormal test results, possibly causing her liver failure and death.
NHS in England
Feb 2023
P-001781 — A practice in the Plymouth area
Mrs E complained the Practice negligently prescribed quinine sulphate without monitoring and an unnecessary duplicate medication, leading to her mother's hospitalisation, injury, and decline.
NHS in England
Feb 2023
P-001984 — The Princess Alexandra Hospital NHS Trust
Mr L complained about limited hospital visits, poor communication, delayed oral thrush diagnosis, inappropriate medication, and inadequate nursing care, including pressure sore prevention, leading to severe deterioration.
NHS in England
May 2023
P-002025 — A practice in the Barnet area
Mrs H complained the Practice overprescribed blood pressure medication without review, refused cardiac monitoring, and failed to provide a fitness to work certificate, leading to her collapse.
NHS in England
Jun 2023
P-002397 — A practice in the Telford and Wrekin area
Mr H complained his GP failed to recognise and inform him of bisoprolol's mental health side-effects and that remote appointments hindered diagnosis, causing him years of suffering.
NHS in England
Jan 2024
P-002441 — Frimley Health NHS Foundation Trust
Ms D complained Trust A wrongly prescribed medication leading to her father's death, and Trust B failed to investigate symptoms or provide adequate hydration/nutrition.
NHS in England
Partly Upheld
Feb 2024
P-002994 — South Tyneside and Sunderland NHS Foundation Trust
Mr F complained the Trust discharged his wife without anticoagulant medication, despite her deep vein thrombosis risk, leading to her death from a pulmonary embolism.
NHS in England
Sep 2024
P-003054 — County Durham and Darlington NHS Foundation Trust
Mr K complained the Trust failed to perform an ultrasound scan and administered anticoagulant medications without checking for internal bleeding, believing these actions hastened his wife's death.
NHS in England
Oct 2024
P-003281 — The Dudley Group NHS Foundation Trust
Miss A complained about medication mismanagement for her mother, including stopping essential drugs, incorrect dosages, and feeding despite aspiration risk, which she believed contributed to her death.
NHS in England
Partly Upheld
Jan 2025
P-003299 — Mersey and West Lancashire Teaching Hospitals NHS Trust
Mrs W complained Mersey and West Lancashire Teaching Hospitals NHS Trust gave her father incorrect medication and restricted visitors, preventing family goodbyes.
NHS in England
Jan 2025
P-003552 — A practice in the North Kesteven area
Mrs P complained the Practice failed to investigate her husband's deteriorating condition and prescribed naproxen without blood tests, potentially causing gastrointestinal bleeding and missing treatment opportunities.
NHS in England
May 2025
P-003726 — Dartford and Gravesham NHS Trust
Ms A complained her mother received inappropriate medication and experienced delayed interventions for respiratory and kidney issues, which she believed contributed to her death.
NHS in England
Not Upheld
Jul 2025
P-003752 — A practice in the East Riding of Yorkshire …
Mr A complained about a seven-hour ambulance delay and a GP practice's failure to review medication, which he believed contributed to his wife's stroke and death.
NHS in England
Jul 2025
P-004074 — A practice in the West Berkshire area
Mrs H complained her brother's GP failed to monitor his Atorvastatin use and blood pressure, and did not refer him for persistent UTIs, contributing to his death.
NHS in England
Sep 2025
P-004025 — Stockport NHS Foundation Trust
Mrs P complained the Trust failed to prescribe her husband blood thinning medication before discharge after surgery, leading to a blood clot, thromboembolism, and his death.
NHS in England
Sep 2025
P-004507 — Northern Care Alliance NHS Foundation Trust
Ms D complained the Trust prescribed contraindicated medication, poorly managed her father's bowel disease, and did not appropriately treat pulmonary embolism, contributing to his death.
NHS in England
Upheld
Oct 2025
P-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-001196 — University Hospitals Sussex NHS Foundation Trust
Mrs W complained the Trust mismanaged her severe back pain, stopping medication and ignoring her history, leading to cancelled surgery and permanent paralysis.
NHS in England
Oct 2021
P-001672 — A medical practice in the Staffordshire area
Mr R complained the Practice failed to detect signs of DVT and pneumonia risk in July 2021, and about delays and inadequate responses to his subsequent complaint.
NHS in England
Dec 2022
P-001663 — Manchester University NHS Foundation Trust
The Trust's rheumatology department failed to offer support or monitoring for medication, a nurse did not help with side effects, a doctor was dismissive, and the Trust delayed its complaint response.
NHS in England
Dec 2022
P-002673 — A practice in the Salford area
Practice incorrectly added multiple cancer diagnoses to her medical file, prescribed inappropriate medication (Duloxetine), and conducted a frailty assessment without her knowledge, causing distress and loss of trust.
NHS in England
Jun 2024
P-002998 — A practice in the Sherwood area
Mrs A complained a practice misdiagnosed her father's AML as a chest infection, delaying diagnosis. She also alleged EMAS incorrectly triaged his ambulance call, delaying treatment for an infection.
NHS in England
Sep 2024
P-003208 — University Hospitals Birmingham NHS Foundation Trust
Mr L complained the Trust failed to provide his mother with take-home potassium supplements and safety netting at discharge, leading to her cardiac arrest and brain damage.
NHS in England
Dec 2024
P-003261 — A practice in the Wigan area
Mrs B complained her mother's blood cancer symptoms were not investigated promptly, antibiotics were inappropriately prescribed, and a contraindicated medication was given, causing harm.
NHS in England
Dec 2024
P-004336 — A practice in the Dudley area
Mrs Q complained the Surgery and Centre wrongly prescribed medication, and the Trust provided inadequate care after a fall, all contributing to her son's death.
NHS in England
Not Upheld
Nov 2025
P-004345 — A practice in the Buckinghamshire area
Mrs A complained the GP failed to adequately treat Mr B’s chest infection and prescribed indapamide during a heatwave without warning, contributing to his death.
NHS in England
Not Upheld
Nov 2025
P-004362 — Imperial College Healthcare NHS Trust
Clinicians wrongly told Miss O she had a heart condition and suffered a heart attack, causing distress and leading to unnecessary medication.
NHS in England
Nov 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-001346 — The Dudley Group NHS Foundation Trust
Ms Z complained she developed a pulmonary embolism due to Depo-Provera injections provided by the Trust, leading to lifelong medication, distress, and worry about her health.
NHS in England
Mar 2022
P-001704 — A practice in the Cheshire West and Chester …
Mr L complained GPs failed to monitor his father's blood pressure, wrongly changed medication, and provided poor complaint responses. He believed this contributed to his father's death.
NHS in England
Partly Upheld
Jan 2023
P-001819 — Cheshire and Wirral Partnership NHS Foundation Trust
Mr O complained the Trust gave him unsuitable antipsychotic drugs without monitoring, misdiagnosed him, and failed to provide post-discharge counselling.
NHS in England
Feb 2023
P-002350 — Manchester University NHS Foundation Trust
Ms A complained about negligent outpatient care, including misdiagnosis of fungal pneumonia, incorrect treatment, and inappropriate physiotherapy, which she claims put her life at risk.
NHS in England
Dec 2023
LGO / SPSO decisions(13)
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
PSOW-202303543 — A GP Practice in the area of Cardiff …
Mr X complained that he had been mistreated by his GP Surgery for 14 years. He said that although he had raised his concerns regarding prescription issues, had a meeting with the Practice Manager, and contacted the Ombudsman previously, he was still encountering issues going forward. The Ombudsman found that …
PSOW (Public Services Om…
Health
Aug 2023
PSOW-202404229 — Powys Teaching Health Board
Ms A complained about the provision of hormone medication to her daughter, Ms B, via the GP and the Local Gender Team within the Health Board’s area. The Ombudsman found that the Health Board did not currently have a consistent pathway for gender patients to be prescribed specialist hormone medication …
PSOW (Public Services Om…
Health
Oct 2024
21-005-391c — Boots UK Limited (21 005 391c)
Summary: We consider Boots UK Limited contributed to delays getting end of life medication to Mrs C before she died. Mr B suffered avoidable distress witnessing his mother in pain before she died. Boots should pay Mr B financial redress to recognise his injustice.
LGO (Local Government & …
Health
Upheld
Mar 2022
21-005-391 — Wirral Metropolitan Borough Council
Summary: We consider Boots UK Limited contributed to delays getting end of life medication to Mrs C before she died. Mr B suffered avoidable distress witnessing his mother in pain before she died. Boots should pay Mr B financial redress to recognise his injustice.
LGO (Local Government & …
Adult Care Services
Not Upheld
Mar 2022
PSOW-202203838 — A Pharmacy in the area of Betsi Cadwaladr …
Mr B complained that he was having difficulties with his medication supply at the Pharmacy. He further complained that despite putting a formal complaint with the help of an advocate, neither he nor his advocate had received a response. The Ombudsman was concerned that the Pharmacy had not yet responded …
PSOW (Public Services Om…
Health
Sep 2022
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
21-005-391a — The Orchard Surgery (21 005 391a)
Summary: We consider Boots UK Limited contributed to delays getting end of life medication to Mrs C before she died. Mr B suffered avoidable distress witnessing his mother in pain before she died. Boots should pay Mr B financial redress to recognise his injustice.
LGO (Local Government & …
Health
Not Upheld
Mar 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
PSOW-202301034 — A Pharmacy in the area of Swansea Bay …
Ms B complained to the Ombudsman that she had not received a response from a Pharmacy in the area of Swansea Bay University Health Board (“the Pharmacy”) to a complaint that she had made to it regarding its prescription and home delivery service. The Ombudsman found that Mrs B had …
PSOW (Public Services Om…
Health
Sep 2023