Poor medicines audit response
Failure to promptly respond to findings from medicines audits and seek current guidance on medication management.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
CQC action
78match
Applegarth Care Home
The service to seek current guidance on how to respond promptly to findings from medicines audit.
Matched on
terms: audit, medicine
PFD report
73match
Mildred Horrex
The coroner identified poor record keeping and insufficient, inaccurate pre-admission information, which resulted in an inadequate fall risk assessment. Additionally, discrepancies between medication charts and actual medication held were not detected by monthly drug audits.
Matched on
terms: audit, poor
PFD report
69match
David Morris
Delays in cancer diagnosis and treatment, alongside a failure to promptly manage a gastrostomy leak and sepsis, resulted in delayed emergency care. The report also notes poor clinical record standards and insufficient controlled drug management systems.
Matched on
terms: poor
CQC action
69match
Colney Lodge Limited
The provider must ensure medicine audits are in place. Medicine administration records (MAR) must be completed accurately and not signed ahead of time. Risk assessments must be in place for managing refusal of medication.
Matched on
terms: audit, medicine
CQC action
68match
Sydenham House
Establish a programme of medicines auditsto ensure staff are practicing in line with current guidance.
Matched on
terms: audit, medicine
Inquiry recommendation
66match
R8 - Medication audit and NICE compliance
Medication should never be used simply to subdue people in the absence of other forms of treatment and good quality care. DoH should issue a regional audit pro forma to measure compliance with National Institute for Health and Care Excellence (NICE) guidelines and Trusts should conduct quarterly audits. These audits should be part of an RQIA review as...
Matched on
terms: audit
PFD report
65match
Cuthbert Hingert
The coroner identified several medication errors, including duplicate antiplatelet prescribing and an incorrect aspirin dosage, alongside a delay in documenting a prescribing decision. Concerns were also raised about insufficient clinician training in the medicines database and a nurse's failure to follow incident reporting protocol for errors.
Matched on
terms: medicine
PFD report
65match
Kumbulani Mtombeni
The coroner raised concerns regarding the security and proper management of prescribed medication within the care home, as methadone prescribed to a resident was found in a staff member's possession. The coroner inquired about audits and actions taken to address this.
Matched on
terms: audit
PFD report
65match
Christopher Bradbury
The coroner raises concerns about a national lack of knowledge and guidelines regarding Severe Invasive Soft Tissue Infections, noting that current training is ineffective. Additionally, there is a lack of an audit trail for omitted medication doses in hospitals when medication is unavailable.
Matched on
terms: audit
CQC action
65match
Westmorland General Hospital
The trust should ensure that Electronic Prescribing and Medicines Administration (EPMA) auditing be strengthened to proactively identify prescribing and administration errors.
Matched on
terms: audit, medicine
CQC action
65match
Montagu Hospital, Mexborough
Thetrustshouldensurethatmedicineauditsarecompletedwithintimescalesinlinewithtrustpolicy.
Matched on
terms: audit, medicine
CQC action
65match
Doncaster Royal Infirmary
The trust should ensure that medicine audits are completed within timescales in line with trust policy.
Matched on
terms: audit, medicine
PFD report
61match
Judith Saville
The coroner identified that medication prescribing did not sufficiently account for a patient's overdose history, and a computer warning system for practitioners was absent. Concerns were also raised about the lack of implementation and auditing of an action plan from a Root Cause Analysis.
Matched on
terms: audit
PFD report
61match
Theresa Robertson
The surgery lacked documentary records of critical telephone calls and a consultation regarding a high-risk patient's prescription. A doctor acted outside surgery guidance for prescription length, and no audit was undertaken to identify other similar instances.
Matched on
terms: audit
PFD report
61match
Margaret Toye
The coroner noted a failure to assess Mrs. Toye for malnutrition risk using the MUST score system, with an incorrect score recorded in her notes preventing further action. Audits revealed that one in ten patients on the ward were not being assessed for malnutrition risks.
Matched on
terms: audit
PFD report
61match
Norman Leadbeater
The coroner noted that Evolve Services' medication administration records and care plans were insufficient for the safe administration of thickened fluids, and a recommended audit to address this was not completed after four months.
Matched on
terms: audit
CQC action
60match
Head Office
We recommend that the provider reviews their medicine administration auditing processes to ensure safe administration of medicines at all times.
Matched on
terms: audit, medicine
CQC action
60match
Royal Victoria Infirmary
The service must ensure a robust audit plan is in place and key audits are conducted, including recordkeeping, daily checks and medicines management audits. The service must ensure relevant actions identified by local audits are acted upon.
Matched on
terms: audit, medicine
PFD report
57match
Benjamin Brown
Concerns relate to the auditing of staff conducting 15-minute observations and clozapine prescription, alongside the training of staff in resuscitation for patient collapse.
Matched on
terms: audit
PFD report
57match
Thomas Jackson
Concerns included poor record keeping, inadequate conduct of multi-disciplinary team meetings, and staff lack of awareness about Clozapine's significance and side-effects. The Serious Incident Review process also contained significant inaccuracies.
Matched on
terms: poor
PFD report
57match
Michael Lobban
Concerns were raised about the slow investigation and incomplete follow-up by Boots regarding methadone tablet disparity, and the lack of robust audit checking for controlled drugs. Additionally, the General Pharmaceutical Council has no reporting requirements, investigative powers, or sanctions for pharmacies discovering Schedule 2 controlled drug discrepancies.
Matched on
terms: audit
PFD report
57match
Alan Hodgson
The coroner identified concerns regarding a Consultant not following an established Vascular Pathway and poor medical-radiology communication, leading to delays. Additionally, the Trust's review was insufficiently robust regarding pathway dissemination, awareness, and staff training for rapid care escalation.
Matched on
terms: poor
PFD report
57match
Trevor Reynolds
The coroner noted delays in fully implementing a new Standard Operating Procedure for managing irregular scan reports and a lack of an audit process to ensure its effectiveness, which allows known risks to patients to continue.
Matched on
terms: audit
PFD report
57match
Seema Haribhai
Concerns included the unregulated status of Ayurvedic practitioners and medicines, inadequate awareness among practitioners of potential harm, and a GP's consultation that lacked detailed examination or timely advice for the patient.
Matched on
terms: medicine
HSSIB recommendation
57match
Medication not given: administration of time critical medication in the emergency department
How does your organisation audit delays or omissions in time critical medications and use this to improve delivery of time critical medication?
Matched on
terms: audit
CQC action
57match
The York Hospital
The trust must ensure adequate action is taken following audits which identify medication storage issues.
Matched on
terms: audit
CQC action
57match
Scarborough Hospital
The trust must ensure adequate action is taken following audits which identify medication storage issues.
Matched on
terms: audit
PFD report
53match
Feni Lee
The thoroughness of Ms Lee's medication review was questioned, particularly for an unlicensed drug where updated specialist instructions were lacking. Additionally, there were significant delays in hospital correspondence being forwarded between two co-located GP practices.
Matched on
classifier match
PFD report
53match
Beryl Ellison
The report raises concerns about Alexandra Care Home's medication management and supervision, with no explanation for the excessive oxycodone found in Mrs Ellison, and the systems remaining unchanged since her death.
Matched on
classifier match
PFD report
53match
Mohammed Hussain
The coroner identified inadequate systems for monitoring and communicating high clozapine levels, and a lack of staff understanding in interpreting and responding to them. This included ineffective medication change processes and insufficient learning from previous concerns.
Matched on
classifier match
CQC action
53match
Newham University Hospital
The services should ensure all drug charts checked by the pharmacist team are clearly documented and audited.
Matched on
terms: audit
CQC action
52match
Tralee Rest Home
Medication audits had failed to identify that equipment used to check blood sugar levels was not calibrated, or that there was no stock of calibration fluid held within the service.
Matched on
terms: audit
CQC action
52match
Oak Tree Manor
There were medication audits but like the other audits they did not pick up on the areas identified at the inspection.
Matched on
terms: audit
PFD report
49match
Peter Brookes
Concerns were raised about the hospital administration of PD medication not following patient regimens, the unavailability of doctors for non-emergency weekend reviews, and the unelucidated cause of a dispensing error involving incorrect medication.
Matched on
classifier match
PFD report
49match
Paul Hardy
Healthcare staff did not follow instructions to obtain blood and urine samples for a possible cancer investigation, nor did they act on recommendations for INR monitoring samples. There was also a failure to conduct a Significant Event Analysis regarding the death, as recommended by the Clinical Reviewer.
Matched on
classifier match
PFD report
49match
William Bows
There were no protocols or guidance for primary care providers on monitoring patients prescribed Amiodarone for liver, thyroid, and respiratory functions. The coroner also noted insufficient monitoring by prescribers during the initial 12 months when toxicity commonly develops.
Matched on
classifier match
PFD report
49match
Kathleen Neville
The coroner noted the absence of a Medication Reconciliation policy at University Hospital of Wales, which made it difficult to identify medication omissions. Concerns were raised that other Health Boards in Wales might also lack this policy, potentially risking future deaths.
Matched on
classifier match
PFD report
49match
Kay Morrison
The coroner identified an insufficient system for collating patients' antibiotic history within the Hospital Trust. They also noted a lack of clear requirements for Trusts to follow existing guidelines on antibiotic history and suggested a need for further Department of Health guidance.
Matched on
classifier match
PFD report
49match
Kathleen Bamforth
The coroner raises concerns about current practice guidelines for clomipramine prescription and suggests considering routine blood screens for patients on long-term clomipramine.
Matched on
classifier match
PFD report
49match
Joan Wright
The coroner identified gaps in GMP's recognition of safeguarding risks related to medication maladministration and insufficient liaison between police units. The report also notes the lack of a statutory definition for 'regular' medication checks in care homes and an uncorrected oversight regarding CCGs' statutory responsibilities for drugs.
Matched on
classifier match
PFD report
49match
Sandra Scott
A GP prescribing system peculiarity meant post-prescription changes inadvertently made medication unavailable, a feature unknown to many professionals. The hospital also did not act on urine test results for a discharged patient.
Matched on
classifier match
PFD report
49match
Elaine Renshaw
The coroner noted insufficient processes for managing controlled drugs in care and nursing homes, leading to difficulties in accounting for medication and inaccurate stock sheets.
Matched on
classifier match
PFD report
49match
Peter Cole
The coroner identified inadequate monitoring and supervision of repeat medication, leading to patients receiving dangerous quantities and widespread waste of healthcare resources.
Matched on
classifier match
PFD report
49match
Ian Allen
The coroner identified that a high clozapine level in Mr Allen's blood was not acted upon, with no system in place to escalate such results to a consultant. Concerns were also raised about a general lack of understanding among mental health practitioners regarding clozapine monitoring and the need for national guidance and education on its importance.
Matched on
classifier match
PFD report
49match
Mohammed Salam
The coroner noted that a Root Cause Analysis investigating a missed medication dose was not sufficiently rigorous, as it failed to examine the factors leading to the omission or its consequences. This raised questions about organisational governance standards and learning from deaths.
Matched on
classifier match
PFD report
49match
Hazel Pearson
The coroner noted slow progress in improving the management of patients with food intolerances/allergies, and a lack of investigation into a specific gluten ingestion incident. Concerns were also raised about insufficient Datix reporting for similar incidents and staff awareness of reporting procedures.
Matched on
classifier match
PFD report
49match
Teresa Bennett
The coroner noted a lack of compliance with medication review targets in GP practices and no standard practice for reviews, leading to variation between clinicians. This raised concerns about the risk of inadvertent overdose when central nervous system depressants are co-prescribed without regular review or specific patient advice.
Matched on
classifier match
PFD report
49match
Debra Bates
The coroner noted that a recommended staggered prescription cycle to limit medication access was not implemented due to concerns about potential confusion and incorrect prescribing. No further investigation was made into how other practices manage such prescribing or available safety measures to prevent errors.
Matched on
classifier match
PFD report
49match
Shahida Khan
Concerns were raised after a care home resident was administered toxic and fatal quantities of medication by staff, with the cause of this administration remaining unascertained, creating a risk of recurrence.
Matched on
classifier match
PFD report
49match
David Crompton
The coroner noted that Mr Crompton was left without anti-epileptic medication for significant periods due to pharmacy supply issues, requiring family members to find alternative supplies. Concerns were raised about the lack of clear designated systems within the pharmaceutical profession to manage medication shortages and ensure patients receive vital medication.
Matched on
classifier match