Poor medicines audit response
Failure to promptly respond to findings from medicines audits and seek current guidance on medication management.
Source spread
Where this theme appears
This theme appears across 10 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
55 PFD reports
3 committee recs
1 HSSIB rec
25 CQC actions
4 PPO recs
1 Scottish FAI
2 DHR recs
2 PHSO 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(55)— showing 50 strongest matches
Judith Marshall
Concerns: The coroner noted concerns regarding the policing of internal pharmacy error records and the lack of mandatory read-back procedures or software to prevent dispensing mistakes. There is also no central database for monitoring prescription errors.
Response (General Pharmaceutical Council): • The General Pharmaceutical Council stated it would review its inspection approach to include further interrogation of recorded errors. • The General Pharmaceutical Council indicated it would highlight its guidance … (AI summary)
Response (NHS England): • NHS England stated it would emphasise the requirement for community pharmacies to report patient safety incidents to the National Reporting and Learning System (NRLS) within the 2014/15 contract. • … (AI summary)
Response (Royal Pharmaceutical Society): • The Royal Pharmaceutical Society stated it would raise awareness and encourage the use of 'read-back' in its guidance. • The Royal Pharmaceutical Society indicated it would raise awareness of … (AI summary)
Response (Department of Health): • The MHRA contacted the marketing authorisation holder for morphine sulphate MR capsules, who agreed to improve packaging, and the MHRA will issue an alert to pharmacists. • An integrated … (AI summary)
Responded
Lee Curran
Concerns: PPO recommendations for high cholesterol and NICE-compliant investigations for loss of consciousness were not fully implemented. The coroner also noted inaccurate medical record entries by prison staff and doctors' lack of awareness regarding NICE guidelines for transient loss of consciousness.
Overdue
Peter Brookes
Concerns: 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.
Response (University College London Hospitals NHS Foundation Trust): • The Trust described measures to ensure timely Parkinson's medication administration, including promoting self-medication and planning staff awareness campaigns. • The Trust detailed its existing weekend medical cover and escalation … (AI summary)
Responded
Mr Pether
Concerns: The coroner noted a lack of focused checks on Mr Pether's limb viability and no re-evaluation of treatment options despite significant delays. The orthopaedic team also did not identify the source of infection even after his clinical condition deteriorated.
Overdue
Judith Saville
Concerns: 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.
Response (Axminster Medical Practice): • The practice confirmed its computer system includes a label advising against repeat or regular Zopiclone use for short courses. • The practice stated that GPs routinely review the summary … (AI summary)
Response (Devon Partnership NHS Trust): • The Trust shared the coroner's findings with the service involved and across the wider trust. • Actions identified in the Root Cause Analysis report have been completed. • The … (AI summary)
Responded
Paul Hardy
Concerns: 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.
Overdue
William Bows
Concerns: 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.
Response (Sheffield Teaching Hospitals NHS Trust): • The Trust stated that a Shared Care Protocol for Amiodarone was in place at the time of the prescription, outlining responsibilities for monitoring. • The Trust confirmed that the … (AI summary)
Responded
Kathleen Neville
Concerns: 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.
Overdue
Maureen Chatterley
Concerns: The coroner identified inadequate stock control and security for non-controlled drugs in patient drawers and ward cupboards at Royal Bolton Hospital, posing a risk of unrecorded removal or excess dosage. This was compounded by insufficient pharmacist checks.
Response (Bolton NHS Trust): • The Medicines Safety Group recently introduced additional measures to audit medicine security using the NHS Protect's Medicines Security Ward/Department checklist. • The Trust committed to introducing a new Wardex … (AI summary)
Responded
Margaret Hions
Concerns: The coroner noted a need to review tinzaparin prescribing practices and blood level monitoring, alongside reiterating the importance of monitoring creatinine clearance according to Health Board policy.
Response (Margaret Hions): • A revised guideline for prescribing and monitoring low molecular weight heparin has been produced. • The importance of monitoring creatinine clearance is being reiterated by letter to clinicians and … (AI summary)
Responded
Benjamin Brown
Concerns: Concerns relate to the auditing of staff conducting 15-minute observations and clozapine prescription, alongside the training of staff in resuscitation for patient collapse.
Overdue
Michael Mahon
Concerns: The coroner noted that Michael Mahon missed a required annual clozapine test in March 2016, and there was no system in place to identify that this test had been missed or to flag it during subsequent monthly checks.
Overdue
Kay Morrison
Concerns: 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.
Overdue
Daphne Penn
Concerns: The coroner noted a more rapid steroid reduction rate was initiated than originally suggested, a delay in transmitting family concerns about the patient's condition to medical staff, and an additional decrease in steroid dose due to a prescribing error.
Overdue
Kathleen Bamforth
Concerns: The coroner raises concerns about current practice guidelines for clomipramine prescription and suggests considering routine blood screens for patients on long-term clomipramine.
Response (Department of Health): • The Medicines and Healthcare Products Regulatory Agency (MHRA) confirmed it is seeking advice from independent experts on the merits of routine blood screens for patients on long-term clomipramine use. … (AI summary)
Responded
Cuthbert Hingert
Concerns: 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.
Overdue
Joan Wright
Concerns: 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.
Response (Department of Health): • The Department of Health detailed existing regulations and guidance for controlled drugs, including the Controlled Drugs (Supervision of Management and Use) Regulations 2013 and NICE guidelines. • A statutory … (AI summary)
Responded
Thomas Jackson
Concerns: 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.
Response (Department of Health and Social Care): • The issue of monitoring clozapine blood plasma levels has been logged for consideration by the NICE guideline surveillance team. • Concerns raised have been added to the MHRA’s adverse … (AI summary)
Overdue
Malcolm Rathmell
Concerns: An incorrect warfarin prescription, resulting from a mislabelled anti-coagulation chart, went unidentified by multiple medical professionals for several days and lacked ward-based pharmacy review. The Trust's proposed actions to address such prescribing errors are still in early stages of implementation.
Overdue
Feni Lee
Concerns: 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.
Response (Bexley Medical Group): • The practice initiated a plan to conduct medication reviews for all patients not reviewed in over 12 months, utilizing new software, and instructed clinicians to undertake opportunistic reviews. • … (AI summary)
Overdue
Michael Lobban
Concerns: 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.
Overdue
Sandra Scott
Concerns: 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.
Overdue
Elaine Renshaw
Concerns: 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.
Overdue
Peter Cole
Concerns: The coroner identified inadequate monitoring and supervision of repeat medication, leading to patients receiving dangerous quantities and widespread waste of healthcare resources.
Response (NHS England): • NHS England stated that Primary Care Networks are able to recruit clinical pharmacists to conduct structured medication reviews for patients with ongoing health problems. • NHS England is undertaking … (AI summary)
Responded
Mildred Horrex
Concerns: 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.
Response (Pelham House): • Pelham House restructured its pre-assessment process, updated paperwork, and implemented a new CQC-recognised care plan system. • The home now employs an external auditor to conduct monthly audits of … (AI summary)
Responded
Theresa Robertson
Concerns: 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.
Overdue
Ian Allen
Concerns: 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.
Response (Birmingham and Solihull Mental Health Trust): • The Trust commenced an audit of patients prescribed Clozapine and is issuing a practice alert to doctors regarding anomalous results. • An additional control has been implemented for the … (AI summary)
Response (Dept Health and Social Care): • The UK product information for clozapine was updated to include advice on monitoring blood clozapine levels for toxicity. • The Medicines and Healthcare products Regulatory Agency (MHRA) communicated advice … (AI summary)
Responded
Katie Corrigan
Concerns: The coroner noted that other doctors and dispensing pharmacists did not contact the patient's registered GP about opiate prescriptions. There is also no formal national procedure for circulating patient alerts to pharmacies, limiting their effectiveness.
Response (CQC): • The CQC inspected the registered online providers identified in the inquest and took regulatory action where concerns were found. • The CQC identified two unregistered online providers and is … (AI summary)
Response (Dept of Health and Social Care): • Officials brought the coroner's concerns regarding the effectiveness of NHS England and NHS Improvement’s (NHSEI’s) alert system to NHSEI’s attention. • The response outlined the existing NHSEI Controlled Drugs … (AI summary)
Responded
Rhian Roberts
Concerns: The coroner noted delays in approving the standard operating procedure for communicating life-threatening blood results and a lack of evidence that a toxicology screen was performed. The report also highlights that ongoing delays in incident investigation and action implementation create patient safety risks.
Overdue
Kumbulani Mtombeni
Concerns: 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.
Response (Care Outlook): • Care Outlook developed an action plan to ensure auditors and managers understood their obligations under CQC regulations for controlled drug administration, including training and ongoing monitoring. • Care Outlook … (AI summary)
Responded
Mohammed Salam
Concerns: 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.
Response (Northern Care Alliance NHS Foundation Trust): • The Trust implemented a process requiring attending consultants to countersign ward round outcomes to verify the accuracy of reviews and management plans. • Grand round and weekend handover proformas … (AI summary)
Responded
Margaret Toye
Concerns: 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.
Overdue
Alan Hodgson
Concerns: 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.
Overdue
Trevor Reynolds
Concerns: 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.
Response (Betsi Cadwaladr University Health Board): • Clinicians and secretaries were made aware of the Standard Operating Procedure for urgent radiology results, and two audits of compliance were completed. • A new electronic solution for results … (AI summary)
Overdue
Karen Redding
Concerns: The coroner noted that care staff provided Oramorph without checking its contents and that a medical review might have been appropriate after the individual disclosed taking an excess dose.
Response (Cherish Home Care Ltd): • The organisation implemented a new procedure requiring staff to seek medical assistance for medication overdoses, irrespective of service user or family wishes. • Medication policies and procedures were reviewed … (AI summary)
Responded
Seema Haribhai
Concerns: 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.
Response (Ayurvedic Professionals Association): • The Ayurvedic Professionals Association (APA) investigated the incident to alert its members and prevent reoccurrence. • The APA will write to the Indian High Commission to suggest a review … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare products Regulatory Agency (MHRA) created a Yellow Card report for the case, using additional information provided regarding the Ayurvedic products. (AI summary)
Overdue
Beryl Ellison
Concerns: 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.
Response (Four Seasons Health Care Group): • The Group reviewed and refreshed its medication competency assessment, reissuing it to all care homes and enhancing training requirements for staff. • A new dependency tool, DepenSys, was implemented … (AI summary)
Responded
John Abrahams
Concerns: The coroner noted a significant delay in implementing recommendations from an expert working group regarding Isotretinoin prescribing for patients under 18, despite ongoing reports of psychiatric adverse events.
Response (Medicines and Healthcare Products Regulatory Agency): • The Commission on Human Medicines (CHM) convened the Isotretinoin Expert Working Group (IEWG) to evaluate data on psychiatric adverse reactions and sexual dysfunction, and the IEWG presented its findings … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Isotretinoin Expert Working Group's report was published on 26 April 2023. • A Drug Safety Update Bulletin was issued to healthcare professionals, detailing new safety measures for isotretinoin. … (AI summary)
Response (Department of Health and Social Care): • The Isotretinoin Implementation Working Group has met three times, with the third meeting occurring on 12 May 2023. • The Group is drafting a report for the Commission for … (AI summary)
Responded
Mohammed Hussain
Concerns: 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.
Response (Response Birmingham and Solihull Mental Health NHS Foundation Trust): • An urgent learning session has been put into place. • A recorded webinar on clozapine interpretation and action will be made available to all clinical staff. • A specialist … (AI summary)
Response (Response Medicines Healthcare products Regulatory Agency): • The MHRA issued a Drug Safety Update article in August 2020 advising monitoring of blood concentrations of clozapine for toxicity in certain clinical situations. • The MHRA will continue … (AI summary)
Responded
Hazel Pearson
Concerns: 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.
Response (Betsi Cadwaladr University Health Board): • The Health Board has rolled out red wrist bands and made associated training live for relevant staff groups, including agency staff and students. • The governance structure for escalation … (AI summary)
Responded
Glenn Lockwood
Concerns: Insufficient monitoring for signs of Pregabalin abuse was identified, particularly given the patient's known history of drug abuse. Concerns were also raised that a Serious Event Analysis exploring potential record-keeping and prescribing issues may not have fully explored relevant risks.
Response (ClydeCo): • The Practice appears to accept that there is some confusion and that notes are not clear regarding prescribing and documentation. • A further serious event analysis is required to … (AI summary)
Response (The Limehouse Practice): • The practice completed a further Serious Event Analysis (SEA) with agreed actions. • The practice will implement three-monthly face-to-face reviews for patients on dependence-inducing medications. • New procedures will … (AI summary)
Responded
Teresa Bennett
Concerns: 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.
Response (Betsi Cadwaladr University Health Board): • Benchmarking work commenced on February 21, 2024, to identify patients requiring medication reviews, with completion by May 31, 2024, followed by risk stratification. • A pan-Health Board policy is … (AI summary)
Responded
Norman Leadbeater
Concerns: 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.
Response (Evolve): • An audit of all Medication Administration Records (MAR) sheets for service users has been completed. • Staff induction and training have been updated, including increased medication observations and the … (AI summary)
Responded
Debra Bates
Concerns: 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.
Response (Park Surgery Heanor): • The practice developed and circulated a new Standard Operating Policy (SOP) for managing 3 and 4-day prescriptions. • A new READ code and home screen alert system were implemented … (AI summary)
Responded
David Morris
Concerns: 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.
Response (Barking Havering and Redbridge NHS Trust): • The Trust implemented an immediate approval requirement for cancer patient tracker list changes and increased its Critical Care Outreach Team to a 24/7 service. • It is restructuring cancer … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The MHRA investigated a safety report in December 2022 regarding a fatality with a gastrostomy balloon device, which it identified as likely relating to the same patient. • This … (AI summary)
Response (Department of Health and Social Care): • The Department stated it would continue to work alongside NHS England and local systems to reduce waiting times and deliver on cancer diagnosis ambitions. • The Department noted that … (AI summary)
Responded
Shahida Khan
Concerns: 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.
Response (Voyage Care): • Voyage Care conducted a further internal investigation, instructed an independent toxicologist to review evidence, and referred the matter to the Police. • The care plans of all residents were … (AI summary)
Responded
Gemma Ralph
Concerns: The coroner noted insufficient monitoring of sevoflurane bottles at Cannock Chase Hospital, allowing one to be removed undetected. The trust could not confirm the origin of a bottle found at the deceased’s home.
Response (NHS England): • NHS England stated it would continue to explore and support improvements in the controlled, authorised, and auditable access to medicines. • NHS England indicated it would consider the hospital’s … (AI summary)
Response (Wolverhampton NHS): • The amount of sevoflurane stored in each theatre has been reduced to two bottles, which are kept under direct supervision and locked away at the end of theatre sessions. … (AI summary)
Responded
Teresa Auriemma
Concerns: Doctors did not follow the policy for treating hypokalaemia, failing to conduct daily U&E monitoring and administering further intravenous potassium without prior checks. The coroner notes a broader pattern of insufficient electrolyte monitoring by the Trust's doctors.
Response (Worcestershire Acute Hospitals NHS Trust): • The Trust issued an advisory notice to all doctors regarding intravenous fluid prescription and electrolyte monitoring. • A working party was established to examine reasons for non-compliance with standards … (AI summary)
Responded
David Crompton
Concerns: 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.
Response (General Pharmaceutical Council): • The General Pharmaceutical Council's Inspection Team inspected the pharmacy to assess its systems for managing out-of-stock medicines. • The inspection found evidence that the pharmacy has robust processes in … (AI summary)
Response (Midway Pharmacy): • The pharmacy changed the wording on its Standard Operating Procedures (SOP) to ensure comprehensive notes are made on patient records detailing outcomes of patient interactions. • The pharmacy reworded … (AI summary)
Responded
Christopher Bradbury
Concerns: 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.
Response (NHS England): • NHS England stated that its Antimicrobial Resistance colleagues will seek to ensure emphasis on escalation of deteriorating patients during the revisiting of statutory and mandatory training for infection and … (AI summary)
Response (University Hospitals of North Midlands NHS Trust): • The Trust had undertaken a training programme and committed to continuing education on Severe Invasive Soft Tissue Infections, emphasising early escalation and senior clinical review. • The Trust had … (AI summary)
Responded
Select committee recommendations(3)
#5 — Review the effectiveness of Serious Shortage Protocols, focusing on timing and administrative burden.
Recommendation: We recommend that the Government reviews the effectiveness of Serious Shortage Protocols, with a focus on their timing and their administrative burden. (Paragraph 49) 44 Pharmacy
Response attribution not verified
#4 — Medicine shortages risk negating general practice capacity gains from Pharmacy First.
Recommendation: It is also especially worrying that shortages are resulting in patients being directed back into general practice. There is a serious risk that any capacity that general practice gains, through services like Pharmacy First, will be negated by the time …
Response attribution not verified
#3 — Medicine shortages undermine community pharmacy potential and erode public confidence.
Recommendation: Tackling medicine shortages is another vital component in securing the ability of pharmacy to meet its future potential. Medicine shortages cannot be ignored and left to become the norm. The wider implications of medicine shortages for the long- term potential …
Response attribution not verified
HSSIB safety recommendations(1)
CQC inspection actions(25)
Westmorland General Hospital
The trust should ensure that Electronic Prescribing and Medicines Administration (EPMA) auditing be strengthened to proactively identify prescribing and administration errors.
Should Do
The York Hospital
The trust must ensure adequate action is taken following audits which identify medication storage issues.
Must Do
Scarborough Hospital
The trust must ensure adequate action is taken following audits which identify medication storage issues.
Must Do
Montagu Hospital, Mexborough
Thetrustshouldensurethatmedicineauditsarecompletedwithintimescalesinlinewithtrustpolicy.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurethatmedicineauditsarecompletedwithintimescalesinlinewithtrustpolicy.
Should Do
Doncaster Royal Infirmary
The trust should ensure that medicine audits are completed within timescales in line with trust policy.
Should Do
Newham University Hospital
The services should ensure teams responsible for antimicrobial stewardship monitor data and provide feedback on prescribing practice to prescriber level.
Should Do
Newham University Hospital
The services should ensure all drug charts checked by the pharmacist team are clearly documented and audited.
Should Do
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.
Must Do
Westmorland General Hospital
The trust should ensure that Patient Group Directions oversight should be strengthened to ensure sure appropriate and timely review and implementation.
Should Do
Scarborough Hospital
The service should review pharmacy CD inspection policy to ensure it is clear how often inspection should take place.
Should Do
Glemsford Surgery
Continue to embed the process to monitor the appropriate level of antibiotic prescribing for uncomplicated urinary tract infections.
Should Do
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.
Should Do
Sydenham House
Establish a programme of medicines auditsto ensure staff are practicing in line with current guidance.
Should Do
Oak Tree Manor
There were medication audits but like the other audits they did not pick up on the areas identified at the inspection.
Should Do
Medrescue Headquarters
Theserviceshouldensureithaseffectiveoversightforthelicensingofcontrolleddrugsandthatapplicationsto renewaremadeinatimelymanner.
Should Do
Head Office
We recommend that the provider reviews their medicine administration auditing processes to ensure safe administration of medicines at all times.
Should Do
Applegarth Care Home
The service to seek current guidance on how to respond promptly to findings from medicines audit.
Should Do
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.
Must Do
Moorcroft Medical Centre
Evaluate and embed the changes implemented during the inspection. For example, older medicine safety alert system searches, monitoring and coding systems for prediabetes patients and the reintroduction of downloading electronic pathology results prior to repeat prescribing.
Should Do
Durham Diagnostics and Treatment Centre
The service should review the system in place at Children’s centre Durham Road to ensure that clinical supplies are in date and audited to avoid out of date stock.
Should Do
Tralee Rest Home
Audits of procedures, such as recruitment, had failed to identify missing steps when convictions were recorded and, additionally, had failed to identify gaps within policies to deal with this.
Should Do
Medrescue Headquarters
Theprovidershouldconsidertheprocessusedtoreceiveandactonmedicinesalerts.
Should Do
Gillmoss Medical Centre
Ensuremedicinessafetyalertsareactedonwithoutdelay.
Should Do
Unit 4 Cornishway Industrial Estate
Operate a stock control system to monitor single use items and ensure that they remain in date
Should Do
PPO death in custody recommendations(4)
The Head of Healthcare
The Head of Healthcare should ensure that the new measures in place are audited at frequent intervals to ensure that pain relief and end of life medications are sourced and dispensed in a timely manner.
The Chief Executive of NHS Wales
The Chief Executive of NHS Wales should investigate whether Parc followed the PGD regulations and whether the use of verbal instructions by GPs for nurses to dispense prescription-only medicines from the out-of-hours medication cupboard complies with regulations.
The Head of Healthcare
The Head of Healthcare should investigate why Mr Walton’s abnormal blood and urine tests were not reviewed by a doctor and put systems in place to ensure that this does not happen in the future.
The Head of Healthcare
The Head of Healthcare should review the systems for medicines management to identify systemic issues with prescribing.
Health investigations(5)
An independent investigation into the care and treatment of Harry … — Rec 14
We recommend that LTHT ensure that the pharmacy service routinely carry out checks on prescription sheets to identify if patients have had repeated missed doses of the same drug. Where there are repeated missed doses, we recommend that LTHT ensure that pharmacy staff escalate these cases to the consultant and …
Leeds and York Partnership NHS Foundation Trust
north_east_yorkshire
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 2
Previous non-compliance with medication should be explicitly identified as part of risk assessment and audited.
north_west
Independent investigation: Ivy Torrie, Pocklington (2003) — Rec 17.3
The ‘issues for consideration’ contained in the document, ‘Recommendations for Antipsychotic Medication Switches’ should form the basis of a clinical audit.
north_east_yorkshire
Independent investigation: Jason Dean, Eston, Middlesbrough (2018) — Rec 1
The Trust should implement an annual audit programme which evaluates the effectiveness of the Trust’s investigation processes against best practice and national guidance. This should include: • a review of the application of RCA methodology; ensure review of medication is a standard part of any investigation. • the panel review …
north_east_yorkshire
A Joint Domestic Homicide Review and independent mental health homicide … — Rec 9
CNTW must assure itself through regular audit that NICE guidance is followed in the prescribing of antipsychotic medication for those with chronic symptoms who have not responded to initial treatment.
Joint Domestic Homicide Review and independent mental health homicide investigation in April 2019 in Northumberland. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
PHSO casework decisions(2)
P-002576 — A practice in the Rutland area
The Practice delayed her referral to Adult Autism Services, included incorrect information, did not review her medication, and wrongly deregistered her.
NHS in England
Apr 2024
P-002567 — A practice in the Suffolk area
Mrs A complained about an unqualified doctor conducting a diazepam review, a second doctor being belittling, and later declines to prescribe diazepam, causing severe anxiety.
NHS in England
Apr 2024
Domestic Homicide Reviews(2)
Leicester — recommendation 10
It is recommended that there should be an effective system in place between inpatient and community service settings to ensure that medication response and dosage is correct and responsive to the patient’s needs. This system should be implemented within two months and monitored at the operational level.
Leicestershire Partnership NHS Trust
Leicestershire Partnership NHS Trust
Northumberland — recommendation 7
Review current practice with regard to prescribing within team and adherence to guidance.
Northumberland Tyne and Wear NHS Foundation …
Cumbria, Northumberland, Tyne and …