Poor medication withdrawal support
Absence of commissioned specialist services for GPs to help patients safely reduce or withdraw from prescribed dependency-forming medications.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
87match
Michael Barry
The coroner identified a continuing lack of a commissioned specialist service for GPs to refer patients to for safe reduction and withdrawal from prescribed dependency-forming medications, which presents a risk of future deaths.
Matched on
terms: medication, withdrawal
PHSO casework decision
80match
P-001226 - A medical practice in the Hartlepool area
Mr R complained a medical practice rapidly reduced and stopped his fentanyl medication without discussion, causing pain and withdrawal trauma, and handled his complaint poorly.
Matched on
terms: medication, poor, withdrawal
IOPC learning recommendation
77match
Care and attention for man whilst detained in custody – Thames Valley Police, June 2021
The IOPC recommends that a review of PACE Code C Annex H is undertaken in relation to the guidance on dealing with detainees withdrawing from drugs and alcohol, including withdrawal symptoms masking other serious problems. The review should include consideration of the dangers of dual medication and amendments to PACE Code C Annex H, point 3, adding that...
Matched on
terms: medication, withdrawal
Scottish FAI
76match
Kieran Nichol
I recommend that consideration be given to devising specific guidance directed towards those providing drug misuse treatment within a residential setting such as Castle Craig where it is likely that the process of titration and stabilisation will be rapid. I recommend that all nursing staff recruited in Castle Craig Hospital to care for drug detoxification patients should undergo...
Matched on
terms: medication, withdrawal
PPO recommendation
73match
The Head of Healthcare
The Head of Healthcare should ensure there is a clinical process for monitoring prisoners who may be withdrawing from psychotropic medication associated with a risk of dependency and withdrawal.
Matched on
terms: medication, withdrawal
PFD report
69match
Ruth Edwards
The coroner noted a surprising discharge from hospital after an overdose without a psychiatric liaison assessment, poor history-taking at UHW, and insufficient GP medication reviews contributing to an overdose risk.
Matched on
terms: medication, poor
PFD report
69match
Danielle Jones
The coroner noted insufficient medication review by the GP for a patient who repeatedly disclosed overdose attempts with prescribed drugs, leading to continued large-amount prescriptions without further clinical rationale. Concerns were also raised about whether communication from a drug and alcohol service reached the treating GP.
Matched on
terms: medication
PFD report
65match
Pauline Meredith
The coroner identified concerns regarding the lack of a formal medication review process for a patient on long-term, high-dose medication, especially the addition of morphine with alcohol dependence. The report also noted a perceived reluctance by the GP to address family concerns and insufficient engagement with community mental health services.
Matched on
terms: medication
PFD report
65match
John Ioannou
The coroner identified a lack of guidance for GPs on managing patients who do not collect medication required for their mental health conditions.
Matched on
terms: medication
PFD report
65match
Tania Hristova
The coroner noted the patient was prescribed antidepressant medication for over five years without adequate review and was not offered additional therapies such as counselling or CBT.
Matched on
terms: medication
PFD report
65match
Craig Hamilton
The coroner identified a lack of clear procedures for managing and monitoring patients who seek to obtain more medication than prescribed, and for exploring alternative pain management during reviews. Concerns were also raised about systems for discussing dosage implications with patients and recording such discussions.
Matched on
terms: medication
PFD report
65match
Jacqueline Campbell
The coroner noted the severe safety risk of polypharmacy involving gabapentinoids and opiates for patients with iatrogenic drug dependency. There were no active plans by the GP practice to identify and rationalize medication for existing patients at risk.
Matched on
terms: medication
PFD report
65match
Aoife McAdam
The coroner noted that the patient was not advised to safely dispose of unused propranolol tablets when switching to a different medication. This left her in possession of a significant quantity of a potentially cardiotoxic drug she no longer needed.
Matched on
terms: medication
PFD report
61match
Paul Nash
The GP surgery did not prioritise an urgent prescription for seizure medication after information about the deceased running out was not fully conveyed. Concerns were also raised about nationwide difficulties for epilepsy patients in obtaining sufficient medication quantities and pharmacy processing delays.
Matched on
terms: medication
PFD report
61match
Lee Bonsall
The coroner noted that citalopram was given on repeat prescription contrary to guidelines, and questioned if GPs were aware of them. Concerns were also raised about ten-month waiting times for psychotherapy, making it an unviable alternative to medication.
Matched on
terms: medication
PFD report
61match
Carly Gordon
Concerns were raised regarding the long-term prescription of shorter-acting benzodiazepines instead of longer-acting ones, contrary to British Association of Psychopharmacology Guidelines. The coroner also noted the need for regular medical review for patients on extended courses of this medication to reassess suitability.
Matched on
terms: medication
PFD report
61match
Marcus Hamilton
The coroner noted GMMH's policy limited prescription supply to 28 days, leading to a patient running out of essential medication on a longer trip and potentially having to source it from an illicit market abroad.
Matched on
terms: medication
PFD report
61match
KennethDaly
The consultant's advice to the GP regarding the continuation of certain pain medications was unclear, and the GP did not seek further guidance. The patient did not receive tailored written advice on his pain relief regimen or the risks of combining multiple opioid medications.
Matched on
terms: medication
PFD report
61match
Amanda Kramer
The coroner noted that Mrs Kramer was prescribed Zopiclone, a short-term medication, for 18 years without clear evidence of review by her GP or mental health trust, even following instances of high-risk behaviour.
Matched on
terms: medication
PFD report
61match
Steven Bowker
The coroner raises concerns about the potential dangers to patients associated with the prolonged prescription and use of opiate medication.
Matched on
terms: medication
PFD report
61match
James Day
The coroner identified inadequate and difficult-to-access mental health support for service personnel with severe PTSD, both during their service and following discharge, which did not fully recognise the impact of traumatic events.
Matched on
terms: support
PFD report
61match
Sarah Keen
The coroner noted insufficient information sharing with carers regarding the patient's self-harm risk and medication management, inadequate communication of discharge medication recommendations by the psychiatrist, and a lack of universal understanding of the "DSH" abbreviation among medical staff.
Matched on
terms: medication
PFD report
61match
Aaron Atkinson
Concerns were raised about the lack of annual ECGs during GP reviews for individuals prescribed long-term anti-psychotic medication. This appears to stem from a lack of clarity and consistency in national and local guidance regarding the recognised cardiac risks.
Matched on
terms: medication
PFD report
61match
Mark Smith
The GP practice lacks a system or policy for appropriate medication reviews, frequency, and volume of repeat prescriptions for vulnerable patients with a history of addiction or self-harm, raising the risk of stockpiling and potential misuse.
Matched on
terms: medication
PFD report
61match
Fallon Adams
The coroner noted concerns that Ms Adams, who was prescribed sedative medication, was not given a specific warning about the risks of over-sedation when combining prescribed and non-prescribed medication. It was also unclear if such specific warnings were being implemented.
Matched on
terms: medication
Article 2 learning point
59match
Mr Everest — HMP Altcourse - LP 1
There needs to be much speedier medicines reconciliation, post reception. In prisoners, like Mr Everest, who are prescribed drugs like antidepressants, this needs to be within 24 hours to avoid withdrawal symptoms. There needs to be a robust administration process whereby a summary is acquired from the GP in the community, outlining the person’s medication. If someone is...
Matched on
terms: medication, withdrawal
PFD report
57match
Lakhminder Kaur
The coroner noted Mrs Kaur's long-term addiction to zopiclone and identified concerns with the decision to abruptly discontinue the medication to prevent self-harm.
Matched on
terms: medication
PFD report
57match
Scott Carton
The report identifies a lack of appropriate psychological support for Mr Carton's emotionally unstable personality disorder and drug dependence in his hostel and prison placements. It also notes insufficient psychological resources for prisoners with similar conditions upon release, impeding successful reintegration.
Matched on
terms: support
PFD report
57match
Michelle Jeffries
The coroner noted an absence of local guidance for GPs regarding the safe oversight of multiple high-dose analgesic prescriptions in the community and when referral to a pain specialist is required.
Matched on
classifier match
PFD report
57match
Jason White
The coroner raised concerns that antipsychotic medication was abruptly stopped and the daily monitoring plan was not followed, creating a risk of relapse and mental health deterioration.
Matched on
terms: medication
PPO recommendation
56match
The Head of Healthcare at HMP Wandsworth
The Head of Healthcare should ensure that the prescribers have a face-to-face conversation with a prisoner if there is an intention to reduce or cease any high risk prescribed medication.
Matched on
terms: medication
PFD report
53match
John Michael Bailey
The coroner noted an absence of clear protocol guidance and a robust system for primary care physicians managing Amiodarone, along with inconsistent Shared Care Protocols across different Trusts, which could pose risks to patients and transferring staff.
Matched on
classifier match
PFD report
53match
Joy Ebanks
The coroner noted prolonged prescribing of two dependency-forming drugs without a clear plan for dose reduction, despite the practice's own guidance highlighting the hazards of long-term opioid and gabapentinoid use for chronic pain.
Matched on
classifier match
NCEPOD recommendation
52match
Crohn’s Disease
Optimise medications for patients with Crohn’s disease. This should include review of: a. The prescription and/or discontinuation of steroids, biologics and immunomodulators b. The use of steroids, with specific reference to bone protection, and when to use proton pump inhibitors (PPIs) c. The provision of a steroid treatment card for all patients receiving steroids for more than three...
Matched on
terms: medication
PFD report
49match
Thomas Pearson
The coroner noted concerns regarding the continued use of fluticasone in patients like Mr Pearson, where it presented an increased risk of pneumonia without corresponding benefits, and suggested a review of its use.
Matched on
classifier match
PFD report
49match
Kathryn Barrow
Mrs. Barrow received Diazepam prescriptions without confirmation from mental health services or adequate GP checks regarding illicit access to the medicine. The practice also had not recently reviewed its approach to prescribing Diazepam.
Matched on
classifier match
PFD report
49match
Louise Rosendale
The coroner noted insufficient review and oversight of long-term opiate prescriptions for patients within the practice. There was also a significant delay between identifying a patient on such a prescription and the next planned action.
Matched on
classifier match
PHSO casework decision
48match
P-002804 - Torbay and South Devon NHS Foundation Trust
Mr E and Mrs O complained their father was not adequately monitored or reviewed, and was inappropriately given sedative medication, potentially leading to his unexpected death.
Matched on
terms: medication
PHSO casework decision
48match
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.
Matched on
terms: medication
IMB recommendation
47match
Cardiff (2023)
Given the frequent applications received by the Board regarding prescription medication, can consideration be given to how the impact of a change to, or ending of, prisoners’ usual medication can be minimised, and prisoners better supported and informed through this?
Matched on
terms: medication, support
PFD report
45match
Deanne Smith
The coroner raised concerns about the policy of dispensing several days' supply of methadone to drug-dependent individuals during public holidays, noting the risk of future deaths when usual provision methods are suspended.
Matched on
classifier match
PFD report
45match
Robert Stevenson
The coroner raises concerns that current guidelines for Ciprofloxacin and Quinolone antibiotics do not sufficiently emphasise a potential rare link to suicide behaviour, noting that prescribing doctors may lack full awareness of this side effect.
Matched on
classifier match
PHSO casework decision
44match
P-002303 - South West Yorkshire Partnership NHS Foundation Trust
Miss H complained the Trust's consultant psychiatrist changed her medication and refused to revert it, which she believes led to her mental health deteriorating and being sectioned.
Matched on
terms: medication
PHSO casework decision
44match
P-002748 - Surrey and Sussex Healthcare NHS Trust
Mrs L complained the Trust incorrectly stopped her mental health medication during admission, delaying its restart and negatively impacting her mobility and mental health, prolonging her hospital stay.
Matched on
terms: medication
PHSO casework decision
44match
P-002761 - A practice in the Hackney area
Miss P complained the Practice abruptly stopped her mother's medication without review, and then lied in its complaint response, which she believes led to her mother's death.
Matched on
terms: medication
PPO recommendation
43match
The Head of Healthcare at HMP Thameside
The Head of Healthcare at HMP Thameside should ensure that prisoners are discharged or transferred with a sufficient supply of their prescribed medications.
Matched on
terms: medication
PHSO casework decision
39match
P-003121 - Cheshire and Wirral Partnership NHS Foundation Trust
Mr R complained the Trust stopped his Clozapine medication without an alternative plan, ignoring concerns and causing a severe 'rebound psychosis' which nearly killed him.
Matched on
terms: medication
PHSO casework decision
39match
P-004419 - Greater Manchester Mental Health NHS Foundation Trust
Mr A complained about delays in preliminary checks and prescribing quetiapine, lack of medication review, and inappropriate discharge of his wife, causing her stress and anxiety.
Matched on
terms: medication
Article 2 learning point
35match
Mr Everest — HMP Altcourse - LP 2
If a prisoner comes into prison on mirtazapine, he/she should have a full review, following confirmation of that prescription from the community GP. This should happen quickly. If an alternative to mirtazapine prescription is appropriate, the person should be reduced slowly from mirtazapine and the new drug introduced gradually, as per the Maudsley Prescribing Guidelines. If mirtazapine prescription...
Matched on
classifier match
PPO recommendation
32match
The Head of Healthcare (HMP Nottingham)
The Head of Healthcare should work in partnership with Nottingham Healthcare NHS Foundation Trust, the regional Health and Justice Leads and regional drug providers to satisfy themselves that the local policy on the offer and issue of naloxone on release captures prison leavers with previous opiate use and other relevant risk factors, not just those on the substance...
Matched on
classifier match