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 13 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
3 CQC actions
2 PPO recs
7 IMB recs
1 Scottish FAI
3 DHR 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 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.
Overdue
Carol Ann Gibson
Concerns: 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.
Overdue
Tripta Rani Kumar
Concerns: The patient's medical notes were altered, removing a documented penicillin allergy without signature or verification, which led to a penicillin-containing antibiotic being prescribed and posed a risk of anaphylactic shock.
Overdue
Bertram Hamilton
Concerns: 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.
Overdue
Teresa Lonergan
Concerns: 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.
Overdue
Kerry Jacobs
Concerns: The coroner noted a lack of documentation for steroid prescriptions outside usual guidelines and insufficient communication with the consultant. There was also no protocol for pharmacists to discuss queried dosages with clinicians.
Response (Surrey Sussex Healthcare NHS Trust): • A directive has been issued requiring staff to record the rationale for prescribing medication outside BNF guidelines and to document discussions with pharmacists regarding queried prescriptions. • The Chief … (AI summary)
Responded
Joseph Godfrey
Concerns: 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.
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
Nicos Michael
Concerns: 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.
Response (East Kent Hospitals University): • The Trust stated there was no consistently recorded allergy to penicillin in the deceased's healthcare records. • The Trust noted the deceased did not articulate a penicillin allergy at … (AI summary)
Responded
Dafydd Watts
Concerns: The coroner noted that the possibility of a rare drug occurrence is not highlighted to physicians in drug literature or in the BNF entry.
Overdue
Akua Anokye-Boateng
Concerns: 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.
Response (Medicine Healthcare Products Regulatory Agency): • The MHRA stated it would publish an article in its September 2014 "Safety Update" bulletin to remind healthcare professionals about the potential for serious gastrointestinal side-effects from NSAIDs. • … (AI summary)
Responded
Lisa Webb
Concerns: 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.
Response (Basildon Road Surgery): • The GP stated they have improved record-keeping practices and now ensure patient reviews are up to date, medication is reviewed, and tests are requested at consultations. • A practice … (AI summary)
Overdue
John Day
Concerns: 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.
Response (Isle of Wight Clinical Commissioning Group): • The Isle of Wight Clinical Commissioning Group stated it is developing a system-wide IT strategy. • This strategy aims to establish a universal, integrated, and readily accessible health care … (AI summary)
Response (Beacon Health Centre): • The Beacon Health Centre sent a reminder to all out-of-hours GPs to consider attempting to access Vision 360 when clinically indicated. • The Beacon Health Centre stated it would … (AI summary)
Responded
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
Christopher Davies
Concerns: 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.
Overdue
Beryl Walters
Concerns: 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.
Overdue
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
Isaac Bahar
Concerns: 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.
Response (Brighton and Sussex University Hospitals Trust): • The Trust followed up with the medical staff involved and conducted a detailed investigation into the prescribing error. • The incident was discussed in detail with general surgeons, the … (AI summary)
Responded
Andre Mickley
Concerns: 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.
Overdue
Lynn Poyser
Concerns: 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.
Overdue
Dorothy Delaney
Concerns: 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.
Overdue
Wayne O’Neill
Concerns: 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.
Response: • Routine annual ECGs are provided for patients prescribed anti-psychotic medication, particularly when combined with other medicines that increase the QT interval; this practice was in place prior to the … (AI summary)
Responded
Mary Bloom
Concerns: The coroner identified non-compliance with Trust policy for heparin administration, specifically regarding weighing the patient, consulting haematology for low weight, and re-attempting baseline bloods. Critical information for underweight patients on the heparin poster was also not sufficiently visible.
Response: • The Trust introduced three new policies and a new chart for the administration of unfractionated heparin. • The Trust's new guideline for heparin administration is weight-based, with APTTR checks … (AI summary)
Responded
Irene Pearson
Concerns: 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.
Response (I Pearson): • Takeda reported the matter concerning heat exposure clarity to Johnson and Johnson. • Takeda requested Johnson and Johnson to review the product information for Durogesic. • Takeda confirmed the … (AI summary)
Response (I Pearson Response2): • The Macmillan team confirmed it would not advise patients to use baths to aid patch removal or submerge patches in water. • A 'Trust Alert' was issued to all … (AI summary)
Overdue
Patricia Thomas
Concerns: 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.
Overdue
Kinga Cieciorska
Concerns: 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.
Overdue
Peter Rowe
Concerns: A penicillin-based antibiotic was prescribed and administered despite a GP referral letter stating a penicillin allergy. Concerns were raised about the deletion of allergy information from the patient's record and the insufficient verification of allergy status, particularly given the patient's cognitive impairment.
Overdue
Edward Mallen
Concerns: 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.
Overdue
Richard Breatnach
Concerns: 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.
Response (NHS England): • NHS England raised the issues arising from this case at the Care Quality Commission National Controlled Drugs Group. • NHS England hosted a multi-agency meeting to discuss issues related … (AI summary)
Overdue
Charles Rendell
Concerns: 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.
Response (Bayer PLC): • Bayer stated that the UK product information for Ciproxin, including the Summary of Product Characteristics (SmPC) and Patient Information Leaflet (PIL), contains warnings regarding the possibility of psychiatric effects, … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) considered the statutory information for Ciproxin and stated that the product information provides up-to-date details on the risk of mental disturbances, … (AI summary)
Responded
Theresa Thompson
Concerns: 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.
Overdue
Claire Medhurst
Concerns: The discharge process did not include cautionary advice on analgesic use, and treating clinicians did not receive alerts from the haematology laboratory for abnormal ALT and toxic paracetamol levels.
Response (Medway NSH Trust): • The Trust stated that staff briefings and daily safety huddles have reinforced the importance of providing essential information on paracetamol overdose upon discharge. • A new flagging system was … (AI summary)
Responded
Stuart Walls
Concerns: 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.
Overdue
Paul Mullen
Concerns: The coroner raises concerns about the 'red flag system' for reporting uncollected methadone prescriptions, noting that reports were routed indirectly through GMMH instead of directly to the patient's Key Worker at Addaction, causing delays. This system did not allow for earlier reporting for diligent patients who missed a single dose.
Overdue
Pauline Pryor
Concerns: 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.
Response (NHS England): • NHS England stated it would raise concerns about interval communication in its GP bulletin and provide information to the Local Medical Committee (LMC). • NHS England stated it would … (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
Paul Ryley
Concerns: 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.
Response (NPIS Clinical Standards Group): • The NPIS added a statement to its TOXBASE guidance for paracetamol overdose. • The statement clarifies that re-presenting patients should be managed as a new presentation. (AI summary)
Responded
Jennifer Lacey
Concerns: 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.
Response (NHS England): • NHS England and the CQC held a workshop in April 2017 to identify challenges in online prescribing and established a UK-wide forum to review the regulatory landscape. • The … (AI summary)
Overdue
Theresa Feehan
Concerns: 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.
Response (CQC): • The Care Quality Commission (CQC) conducted a focused inspection of Lisson Grove Health Centre in March 2019, prompted by the prevention of future death report. • Following challenges from … (AI summary)
Overdue
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
Chand Ali
Concerns: 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.
Response (Barts Health NHS Trust): • The Trust's lead pharmacist completed a review of the evidence for cyclizine use in severe heart failure and considered alternative anti-emetic drugs. • The Trust stated it would warn … (AI summary)
Responded
Mohammed Ahmed
Concerns: 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.
Response (Department of Health): • The Medicines and Healthcare products Regulatory Authority (MHRA) stated it would keep the issue under scrutiny through its Yellow Card scheme and a national pilot for reporting illicit drug … (AI summary)
Overdue
Christopher Summerhayes
Concerns: 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.
Response: • The Health Board confirmed that the death was reported to the Medicines and Healthcare products Regulatory Agency (MHRA) and detailed existing systems for Clozapine monitoring, polypharmacy reviews, and medicines … (AI summary)
Responded
Deborah Chapman
Concerns: 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.
Response (West Timperley Medical Centre): • The Primary Care Team discussed Mrs Chapman's death, emphasising the need to maintain up-to-date records of all illicit drug use. • The medical centre conducts regular clinical system searches … (AI summary)
Responded
Graham Saffery
Concerns: The British National Formulary (BNF), a resource regularly consulted by GPs, does not appear to include advice for caution and monitoring when prescribing amitriptyline and oxycodone simultaneously, unlike other pharmacological guidance.
Response (Bedfordshire CCG): • The CCG discussed the case at its Prescribing Committee and shared the learning across all practices. • A SystmOne search was developed and published to identify patients on high-strength … (AI summary)
Responded
Graham Earl
Concerns: The coroner noted GPs' insufficient understanding of a medication's link to pulmonary fibrosis and their lack of awareness regarding escalation procedures for side effects. Additionally, a GP amended a secondary care prescription without consulting the prescribing physician.
Overdue
Abdeslam Benelghazi
Concerns: The coroner noted concerns regarding the concurrent prescribing of clonazepam with methadone. This combination can cause central nervous system and respiratory depression, increasing the risk of sudden death, particularly given clonazepam's long half-life.
Response (Department of Health and Social Care): • The Medicines and Healthcare products Regulatory Agency (MHRA) is contacting marketing authorisation holders to update product information for clonazepam and methadone, and will remind healthcare professionals of co-prescribing risks. … (AI summary)
Responded
Katherine Stamp
Concerns: The coroner noted that clozapine's side effects, especially relating to smoking and pneumonia, are under-appreciated, and the BNF does not provide sufficient clarity to prescribers regarding these effects.
Overdue
Mary Nelson
Concerns: 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.
Overdue
Shanté Turay-Thomas
Concerns: GPs did not fully appreciate their role in managing high-risk allergies, including advising on two adrenaline auto-injector pens, dose adjustment, and device training. The CCG provided inaccurate guidance to prescribers regarding auto-injector scriptswitches.
Response (NHS England): • NHS England committed to ensuring the report is sent to Health Education England and the Royal College of General Practitioners. • Its commissioning teams will liaise with relevant organisations … (AI summary)
Response (Advanced): • Advanced issued a reminder to call handlers and released a software update to prevent manual circumvention and override of address details. • Advanced is developing further changes to the … (AI summary)
Response (National Institute for Health and Care Excellence): • NICE stated that the British National Formulary (BNF) and BNF for Children (BNFc) already contain detailed advice on adrenaline auto-injectors, including dosage, number of pens, and training. • NICE … (AI summary)
Response (Bausch Lomb): • Bausch & Lomb will initiate discussions with the MHRA regarding adding advice about carrying two pens to the outer packaging of adrenaline auto-injectors. • Bausch & Lomb distributes trainer … (AI summary)
Response (Radcliffes Le Brasseur): • The Practice conducted an audit of all adrenaline auto-injector (AAI) prescriptions, reviewed doses, and updated patients with current advice and MHRA alerts. • In-house training on anaphylaxis management and … (AI summary)
Response (NHS England): • NHS Pathways was updated in October 2019 to ensure symptoms suggesting life-threatening anaphylaxis receive a Category 1 ambulance response. • An amended distance learning pack for 111 call handlers … (AI summary)
Response (London Ambulance Service): • The London Ambulance Service provided a detailed summary (Appendix 2) explaining how UK Ambulance Services manage 999 calls and national prioritisation. • The London Ambulance Service stated it would … (AI summary)
Response (Department of Health and Social Care): • The Commission on Human Medicines agreed to convene an Expert Working Group on Adrenaline Auto-Injectors (AAIs) to provide independent clinical advice, and the MHRA is developing a communication campaign … (AI summary)
Response (Enfield CCG): • The CCG distributed a Medicines Safety Bulletin on Adrenaline Auto Injectors to primary care professionals and issued updated scriptswitch messages and policy statements regarding AAI use and dosage. • … (AI summary)
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 …
Response attribution not verified
#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), …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
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
NCEPOD recommendations(2)
CQC inspection actions(3)
Andover War Memorial Hospital
The service should ensure there is pharmacy oversight and support towards and departments.
Should Do
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
Health investigations(3)
Report of a review in respect of: Mr N and … — Rec 2
HMP Cardiff, HMP Parc, Abertawe Bro Morgannwg University Health Board, Aneurin Bevan University Health Board and Cardiff and Vale University Health Board should ensure procedures are in place to check the rationale for prescribed medication, especially when an individual presents a history of non-compliance.
wales
*Independent investigation into the care and treatment of Patient G: … — Rec 13
Where polypharmacy is a feature of clinical management, expert advice should be sought from either hospital or community pharmacists on optimal dosing and potential adverse effects.
Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Accepted
Independent investigation: Jim Ward, Ayr (2007) — Rec 5
NHS Board A must examine the availability of clinical pharmacy support to all mental health teams and this should include reference to current good practice guidance on the use of licensed medicines for unlicensed applications (Royal College of Psychiatrists CR142)
scotland
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
Domestic Homicide Reviews(3)
South Gloucestershire — recommendation 5
South Glos and Bristol substance misuse services to ensure communication between treatment providers and pharmacies- with particular focus on information being shared on the initiation and cessation of opiate substitution therapy prescriptions.
South Gloucestershire Council | Bristol City …
South Gloucestershire Council
Barnsley — recommendation A3
Send a reminder to all practices to constantly review their repeat prescribing system to avoid duplication of the same class of drug. At the same time make practices aware of the risk of hoarding where there are multiple items on a repeat prescription.
NHS Barnsley ICB
Fenland — recommendation 10
Stronger working relationships and communication channels are required between the GPs and pharmacists to prevent any delay in the administering of prescriptions with an escalation process or safety plan to address issues when a technical error occurs and is identified.
GP Practices | Pharmacists