Unsafe medication management
Failures in the safe management of medicines, including storage, administration, record-keeping, prescribing, and disposal.
Source spread
Where this theme appears
This theme appears across 21 independent accountability sources, so the source mix matters as much as the headline total.
3 inquiry recs
118 PFD reports
5 committee recs
109 HSSIB recs
690 CQC actions
17 PPO recs
2 IOPC recs
16 IMB recs
10 IMB reports
6 Scottish FAIs
1 detention investigation rec
49 DHR recs
45 PHSO decisions
3 LGO/SPSO decisions
5 CQC enforcement actions
2 MNSI reports
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.
Inquiry recommendations(3)
2 — Insulin
Recommendation: i. Digital devices should be used to restrict access of insulin to authorised people and record access to insulin storage units. I acknowledge that steps are being taken to achieve this. By 31 March 2027, all neonatal units must meet …
Gov response: It recommends much stronger controls on insulin storage. The NHS has begun that process with new guidance in January of this year, but we agree with the recommendation to go further.
Accepted
R8 — Medication audit and NICE compliance
Recommendation: 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 …
No response yet
F242 — Medicines administration
Recommendation: In the absence of automatic checking and prompting, the process of the administration of medication needs to be overseen by the nurse in charge of the ward, or his/her nominated delegate. A frequent check needs to be done to ensure …
Gov response: Accepted. In the initial Government response to The Inquiry, Patients First and Foremost, the Department of Health gave strong support to supervisory roles for Ward Managers (including Sister, Charge Nurse and Team Leader) in delivering …
Accepted
Prevention of Future Deaths reports(118)— showing 50 strongest matches
Harold Elvidge
Concerns: The coroner noted inconsistent availability of Omnicell cabinets across the trust and raised concerns about the risk of different fluid types being mixed up in non-critical care settings. A trust-wide review of policies for safe fluid storage, including packaging and labelling, was suggested.
Overdue
William Kent
Concerns: The coroner noted a lack of awareness and clarity regarding the safe use and potentially harmful side-effects of Haz-Tab granules for urine spillages, compounded by limited teaching during staff induction and updates.
Overdue
Richard White
Concerns: The coroner noted that Hope House lacked a clear and accessible policy or protocol regarding the administration and holding of medication by staff, which was not made known to prescribers or other relevant personnel.
Response (700 Club2): • The organisation stated that it does not store or administer medication to clients as a matter of policy. • The organisation confirmed that if a client voluntarily surrenders medication, … (AI summary)
Responded
Derrick Rivers
Concerns: The coroner identified inadequacies in the care home's drug administration policy and audit processes, which were not fully noted by the Local Authority or CQC during inspections. Concerns were also raised about management's awareness of staff not following protocols and delayed action on recommendations.
Overdue
Afifa Qaisar
Concerns: The coroner identified issues with inaccurate drug administration records, unavailability of resuscitation equipment, the patient not being notified to the RMO, delays in platelet transfusions, and a lack of fluid balance charting.
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
Edward Devlin
Concerns: The coroner identified a practice where nurses reportedly slide medication, including controlled drugs, under cell doors rather than directly handing it to patients. This raises concerns about whether patients receive their medication, the accuracy of drug records, and the potential for drug misuse or trading within the establishment.
Response (Care UK): • An investigation was commenced into the nurse's claim regarding medication administration practices. • Healthcare staff were interviewed, and a staff meeting was held to discuss the claim. • A … (AI summary)
Overdue
Donna Kirkland
Concerns: The coroner noted patients had unlimited access to alcohol-based hand sanitising gels and were permitted to decant and keep them in their rooms. There was also a lack of staff awareness regarding the gel's alcohol content and potential for ingestion.
Response (Coventry and Warwickshire Partnership NHS Trust): • The Trust completed the replacement of wall-mounted alcohol-based hand sanitiser dispensers with an alcohol-free alternative. • The Trust reviewed access to and use of alcohol-based hand sanitiser across inpatient … (AI summary)
Response (Department of Health): • The Care Quality Commission inspected the Caludon Centre twice and required immediate improvements. • The Department of Health will maintain national oversight of reports and learning from such incidents. (AI summary)
Responded
Iris Grimwood
Concerns: The coroner identified difficulties in providing adequate nursing care, including errors in temperature measurement and incorrect medication application. These issues were attributed to insufficient nursing staff levels, recruitment challenges, and training funding problems.
Overdue
Marjorie Phillips
Concerns: The coroner noted concerns regarding a hoist sling's tendency to "bag" at the sides, which could allow a patient to fall if they leaned to one side during transfer.
Response: • Sunrise Medical Limited provided Instructions for Use (IFU) documents for their hoists. • The IFUs advise users to check slings for wear or damage, including 'bagging,' before each use. … (AI summary)
Overdue
Beatrice Gatt
Concerns: An error in transferring medication details between Mars sheets led to Mrs Gatt not receiving her anti-psychotic medication, with the coroner noting a lack of formal training for nursing staff on these procedures.
Overdue
Alan Peck
Concerns: A patient's prescribed medication was not delivered due to an unconnected syringe driver on a surgical ward, and the device was then not transferred with him to hospice, interrupting his essential pain relief.
Overdue
Philip Allen
Concerns: The coroner noted that specialist advice was not followed and a medication the patient had stopped was repeatedly prescribed. Concerns were raised about the system at Eltham Palace Surgery that allowed this to occur, and the lack of clarity on whether improvements have been made.
Response (Eltham Palace Surgery): • The practice conducts twice-weekly ward rounds at the Oaks Home and performs regular medication reviews every three months by a Prescribing Advisor and twice a year by the attending … (AI summary)
Responded
Moses McDonald
Concerns: The coroner noted a lack of mandatory and regular glucose testing for patients on antipsychotic medication by the Clozapine clinic.
Response (South London Maudsley NHS Trust): • The physical healthcare policy has been updated to outline staff responsibility for addressing patients' physical health needs, including reference to Maudsley Prescribing Guidelines for Clozapine. • The Trust pharmacy … (AI summary)
Overdue
Patricia Edge
Concerns: The coroner identified concerns regarding the prescription and dispensing of an excessive paracetamol dose, a lack of subsequent dose review, and the failure to conduct blood tests that would have revealed this issue.
Response (Bolton NHS Trust): • The Trust reviewed its process for prescribing paracetamol and revised its practice to include regular monitoring by the clinical team. • An SBAR (Situation, Background, Assessment and Recommendations) detailing … (AI summary)
Overdue
Andrew Aitken
Concerns: Concerns included inadequate handling of medication, failure to obtain historical psychiatric records for a patient without a GP, and discharge deficiencies such as lacking direct mental health referral and appropriate clothing.
Response (Barts Health NHS Trust): • An investigation was conducted into the handling of medication, confirming that tablets were secured in a medicine cupboard for destruction after a staff member was unable to contact a … (AI summary)
Response (East London NHS Trust): • The Rapid Assessment, Interface and Discharge (RAID) Operational Policy will be updated to include the importance of obtaining collateral information. • Staff will be made aware that patients can … (AI summary)
Responded
Leonardus Vries
Concerns: The coroner identified significant documentary failings in medication control at the Royal Orthopaedic Hospital, specifically the absence of an audit or paper trail for non-controlled medication, creating opportunity for misuse. The coroner suggested the Trust implement its own audit guidelines to address this gap.
Response (Royal Orthopaedic Hospital): • A letter was issued to all staff in February 2015 clarifying individual responsibilities for the safe and secure handling of medicines, and Standard Operating Procedures (SOPs) were issued to … (AI summary)
Responded
Darren Linfoot
Concerns: The coroner noted that non-controlled drugs, including opiates, are not audited, posing a risk of potent medication being unaccounted for. There was also a lack of consistent understanding and methods among nursing staff for performing regular patient observations.
Overdue
Laurence Boyens
Concerns: Coroner noted insufficient compliance with drug dependence guidelines, specifically regarding blood pressure monitoring before Methadone/Buprenorphine administration and escalation of low readings. Gaps in record-keeping and recognition of patient drowsiness were also identified.
Response: • The organisation commenced a review of its decision to close a case regarding Dr Amayo's care. • The organisation obtained the doctor's comments as part of this review. • … (AI summary)
Response: • The Nursing and Midwifery Council (NMC) stated it would conduct an initial assessment of the referral. • The NMC indicated it would determine how to proceed following the assessment. … (AI summary)
Overdue
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
Lottie Reid
Concerns: The coroner noted a discrepancy between medication records following hospital discharge and a lack of a protocol to easily check such discrepancies, particularly on weekends.
Response (Birmingham Heartlands Hospitals): • The Trust is sending a clinical alert to all wards at Good Hope Hospital to reinforce the Intermediate Care Procedure. • The Trust is amending the nursing discharge checklist … (AI summary)
Responded
Geoffrey Parry
Concerns: Concerns included a recurring problem with investigative test results not being available with patient notes or electronically uploaded, and the absence of a protocol or labels for intravenous lines, which contributed to an accidental disconnection.
Response: • The Health Board reviewed systems and processes for ECG investigations and is developing an improvement plan for the MUSE system. • An improvement plan for intravenous infusion labelling practice … (AI summary)
Responded
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
Betty Addison
Concerns: The coroner raises concerns about insufficient control over medication administration and monitoring at Alexandra Court Care Home, noting that residents may receive incorrect amounts of prescribed medication.
Overdue
Derrick Twiate
Concerns: The coroner noted that pharmacists in general practices continue to snip tablets from unit dose packs into multi-dose compliance aids, a practice contrary to professional body advice.
Overdue
Michael Hutchence
Concerns: The report identified issues with frequent patient transfers, poor medical record-keeping, and an inconsistent method for anti-coagulant dosing. Concerns were also raised about shortages of trained nurses and essential equipment, leading to surgical delays.
Response (Stockport NHS Trust): • The Trust is installing an electronic patient record system, with completion anticipated in 2017. • Monthly spot audits of 30 inpatient records are being conducted across wards to improve … (AI summary)
Responded
Daniel Paylor
Concerns: The coroner identified insufficient regulatory control, safeguards, and auditing for drugs in secondary employment settings, particularly noting a lack of peer supervision and double authorisation for accessing safes.
Overdue
Lyndsey Holt
Concerns: The coroner identified issues with prescribing methadone over the telephone without a face-to-face consultation, which resulted in insufficient patient information. Additionally, providing a methadone-naive patient with a seven-day supply lacked initial medical review.
Overdue
Steven Fone
Concerns: The coroner noted a pharmacy allowed customers to interchangeably collect each other's prescriptions without documented consent, raising concerns this practice could facilitate abuse, stock-piling, and increased risk of harm.
Overdue
Kymberley Holden
Concerns: The coroner noted ongoing risks from unsafe prescribing of controlled drugs by Ivy Grove Surgery and a limited understanding of reporting serious prescribing incidents. Concerns were also raised about poorly coordinated management and prescribing for neurological patients under shared care.
Overdue
Patricia Parker
Concerns: The coroner noted that guidelines relating to sedation use should be more widely disseminated to clinicians. NHS England should also highlight the problems of sedation, particularly in the elderly, and encourage local training for hospital staff.
Overdue
Songul Bozdag
Concerns: The coroner noted gaps in the care co-ordinator's mandatory reviews and record-keeping for Ms Bozdag, including unrecorded discussions and failure to update her drug card, resulting in under-medication.
Response (East London NHS Foundation Trust): • An Inbox-based system was implemented to communicate discharge care plans and monitor actions, including medication changes. • Monthly supervision for care coordinators was reinforced, with regular audits undertaken to … (AI summary)
Responded
Jennifer Midgley
Concerns: The drug administration chart does not clearly differentiate between oral and intravenous paracetamol, nor does it include a patient's weight reference for intravenous administration, which is needed to modify dosage.
Overdue
Christopher Roberts
Concerns: Care plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. Additionally, Nomad trays might be unsuitable for certain patients, impeding medication benefits.
Overdue
Christina Fletcher
Concerns: The coroner noted the absence of specific guidance from the GPhC for pharmacies on 'red flag' systems for patients with similar identifying details. Concerns were also raised about the lack of clear guidance on the chain of custody for Controlled Drugs, leading to inconsistent local practices.
Overdue
Ronald Brewer
Concerns: Concerns were raised regarding the administration of medications, with particular note on the documentation and dispensation of palliative medications.
Response (Barchester Healthcare): • A Deputy Manager with a palliative care background was appointed to support training and practice in end-of-life care. • Staff completed competency assessments and further training on medicine management, … (AI summary)
Responded
Percy Jacks
Concerns: The coroner identified inadequate communication between hospital, GP, and care home, including misdirection of scan results. Concerns also noted the GP surgery's poor system for reviewing prescribed medication dosage and duration.
Response (Welsh Government): • Healthcare Inspectorate Wales (HIW) is undertaking a review of discharge arrangements, focusing on communication and documentation. • The Regulation 28 report has been shared with the lead for the … (AI summary)
Response (Rhayader Group Practic): • The practice implemented new procedures for administrative staff to record and follow up on suspected DVT referrals and to inform patients with positive DVT diagnoses about their prescriptions. • … (AI summary)
Response: • A streamlined DVT patient management process and a definite pathway have been introduced. • An investigation was undertaken into the incorrect addressing of the deceased's discharge summary. • The … (AI summary)
Response (CQC): • The CQC revised and improved the wording of its Key Lines of Enquiry for inspections, to be used from November 2017, to clarify how providers meet information transfer requirements … (AI summary)
Responded
Hayley Sheehan
Concerns: The procedure for repeat prescription requests relies on administrators to identify early requests, as the surgery's software does not automatically flag them. More safeguards are needed to ensure these requests are identified and brought to a GP's attention.
Response (The Moat House Surgery): • The surgery sent an email to EMIS Health requesting changes to the prescribing process to flag early prescription requests. • The IT Manager developed a pop-up box within patient … (AI summary)
Responded
Carly Gordon
Concerns: 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.
Response (Fremington Medical Centre): • The General Practitioner stated they would change future prescribing practice regarding the use of shorter-acting benzodiazepines. • The practice implemented a structured systemic approach for reviewing patients on benzodiazepines. … (AI summary)
Response (Royal College of General Practitioners): • The Royal College of General Practitioners (RCGP) provides guidance on benzodiazepine use, including a 2013 consensus statement. • The RCGP curriculum includes safe prescribing and medicines management approaches, which … (AI summary)
Response (NHS England): • NHS England stated it would ask its National Clinical Director for mental health and Head of Mental Health and LD Medicines Strategy to write to medical directors and chief … (AI summary)
Response (Devon LMC): • Devon LMC stated it would remind practices about reviewing patients receiving short-acting benzodiazepines via its electronic newsletter. • Devon LMC stated it would make the information available on its … (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
Russell Robb
Concerns: The coroner identified a lack of regular medication reviews and no guidelines to limit medication availability. Additionally, limited information sharing within the Trafford Adult Safeguarding Board hindered awareness of police interactions with Mr Robb and restricted strategic oversight.
Response (Trafford Safeguarding Board): • Greater Manchester Police (GMP) now records high volume callers more accurately and has co-located its prioritisation and allocation function within the Partnership Office. • The adult social care Screening … (AI summary)
Responded
Patrick Moran
Concerns: The anaesthetic department commonly used non-insulin syringes for insulin administration, despite a national alert. Additionally, doctors lack mandatory training on insulin devices, and no process exists to check compliance with safety alerts.
Overdue
David Green
Concerns: The coroner identified concerns regarding the absence of a safe system of work on site, a widespread practice of employees not wearing seatbelts, and an inadequate system for checking seatbelt compliance.
Overdue
Sandra Miller
Concerns: The coroner identified a need to stop the practice of allowing open-ended urinary catheters to drain freely, establish proper procedures for catheter management with specialist advice, and ensure all staff are adequately trained in their care.
Overdue
James Quinton
Concerns: Poor quality nursing notes and observation charts hindered consultants' understanding of patient events. The coroner also identified a lack of checking procedures for verbally prescribed medications, which led to an incorrect drug administration.
Response (Doncaster Bassetlaw Teaching Hospital): • The Emergency Department commenced training individuals as scribes to improve observation recording during resuscitation. • A working group was established to explore IV drug administration systems and processes in … (AI summary)
Responded
Jean Griffiths
Concerns: The coroner noted concerns regarding poor prescribing practices for oxygen, with a significant percentage of patients receiving supplementary oxygen without a valid prescription. This poses a risk that patients may receive inappropriate oxygen levels, potentially increasing mortality.
Response (Department of Health): • Department of Health officials sought advice from the National Institute for Health and Clinical Excellence (NICE) regarding further action on oxygen prescribing. • NICE's guideline on Chronic Obstructive Pulmonary … (AI summary)
Responded
Joan Osborne
Concerns: Concerns included the nursing home's failure to seek specialist diabetes and dementia outreach assistance, adequately manage Mrs Osborne's insulin refusal, or recognise her deteriorating condition. Inadequate record keeping and incorrect medication administration were also noted.
Response (Adbolton Hall Ltd): • The nursing home implemented new training for staff on nutrition and diabetes management, including the use of new blood glucose monitoring machines. • Care plans for diabetes management were … (AI summary)
Responded
Barbara Haley
Concerns: Concerns were raised that a resident, assessed as high risk of choking and on a soft diet, was provided unsuitable food items and left unattended while eating.
Overdue
Mike Fell
Concerns: The coroner noted a lack of documentation for checking that unused trauma line taps were closed to air, and that the trauma lines themselves did not come with clamps to close unused lines.
Response (Barts NHS Trust): • The Trust re-wrote its policy on central lines and three-way taps, stating that self-sealing injection ports should be used instead of three-way taps on central lines. • A Trust-wide … (AI summary)
Response (Royal College of Anaesthetists): • The Royal College of Anaesthetists (RCoA) will publish information on central venous access issues in the Patient Safety Update. • Issues related to central venous access will be included … (AI summary)
Responded
Jonathan Earp
Concerns: The coroner noted no clear evidence that all unspent Fentanyl patches were returned or discarded appropriately. Staff also did not fully consider the potential impact of a patient taking additional prescribed medication alongside illicit drugs.
Response (Gloucestershire Hospitals NHS Trust): • The Trust reviewed the circumstances of fentanyl administration to Mr Earp. • The case was discussed with ward staff and presented to the Senior Nurse and Midwifery Committee. • … (AI summary)
Responded
Select committee recommendations(5)
#6 —
Recommendation: In some cases the failure of provision of homecare medicines is so severe, or so predictable, that NHS services are compelled to use their resources for services which should be delivered by homecare providers. The NHS can pay twice—once for …
Response attribution not verified
#3 —
Recommendation: While we welcome the current work on homecare medicines services, we are concerned that it is vague, lacks specific commitments, and has no clear leadership. Serious problems in homecare have been apparent for over a decade. It is now time …
Response attribution not verified
#168 — Implement new secure systems for distributing and administering prison medication to prevent diversion.
Recommendation: HMPPS should conduct an urgent review of all prescription medication dispensing procedures within prisons to identify and close loopholes exploited for diversion and introduce enhanced supervision of medication queries. New secure systems for distributing and administering medication must be implemented …
Response attribution not verified
#24 — Commission independent review into hospital medicines management, focusing on automation and digital systems.
Recommendation: We recommend that an independent review is commissioned to explore hospital medicines management, to report within one year. The review should make recommendations, particularly around how the potential of automation and technological systems like connected medication management could be realised …
Response attribution not verified
#23 — Strategic oversight lacking for widespread adoption of automation in hospital medicines management.
Recommendation: There are clearly benefits to be found from using automation and technology particularly within hospital medicines management. These benefits could unlock gains in productivity, improve patient safety and free up pharmacist time to work more directly with patients. There are …
Response attribution not verified
HSSIB safety recommendations(109)— showing 50 strongest matches
Insulin: supporting safe self-administration for patients in the community with a learning disability
HSSIB recommends that the National Institute for Health and Care Research, in collaboration with relevant research and policy stakeholders, assesses the feasibility of research, and supports its commissioning, to address the gaps in knowledge around services, device and technology requirements …
Safety Recommendation
Mental health: attempted suicide while under the care of community services
Staff knowledge and insight into how community mental health services can support service users who may require prescription medication and who use drugs and/or alcohol.
Area of Improvement
Insulin: supporting safe self-administration for patients in the community with a disability
Does your organisation have systems and processes to identify where patients have not requested their repeat medication prescription, or the frequency of the requests have changed, which may indicate changes in their circumstances?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How to adjust the insulin dose was discussed, as well as injection technique. The patient was given leaflets which detailed injection technique and what to do in the event of illness, and type 2 diabetes and healthy eating booklets were …
Learning Prompt
Medication not given: discharge from an acute hospital to the community
Does your organisation support staff to make timely and effective referrals to district nursing services to support insulin administration?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation follow up with patients post discharge, whose insulin regimen has started or been changed while in hospital?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation support staff to complete medication checks before patients are discharged home with medications?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation support staff to ensure that medications for an individual patient that are no longer needed are disposed of safely?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation consider family, carer or living arrangements when providing education on self-administration?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation support patients to understand how to raise concerns about self-administration of insulin?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation support patients to feel confident and safe in self-administration of insulin?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation ensure that education given to patients emphasises the importance of taking insulin and is appropriate and tailored to their individual needs?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation support staff to quickly and easily identify what medication a patient is currently taking and their medication history?
Learning Prompt
Medication not given: anticoagulation before and after a procedure
Does your ePMA system identify patients with paused time-critical medication that may warrant a review?
Learning Prompt
Medication not given: anticoagulation before and after a procedure
Does your organisation have systems and processes in place that support regular risk assessment of anticoagulants that have been paused?
Learning Prompt
Medication not given: anticoagulation before and after a procedure
How does your patient record system support staff to document and clearly display the rationale behind any decision to pause anticoagulant medication?
Learning Prompt
Medication not given: anticoagulation before and after a procedure
How does your organisation support staff to identify and document decision making at critical decision points where anticoagulation should be reviewed?
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
How does your ePMA system help to alert staff to patients who need time critical medications?
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
A dose was prescribed but not given on day 3.
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
When the medication was prescribed, the morning dose was incorrect.
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
The first eight doses were not prescribed during the patient’s first 24 hours in the ED. The patient self-administered the first four doses.
Learning Prompt
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
Medication not given: administration of time critical medication in the emergency department
What aids or tools are available in your organisation to help staff to identify patients who need time critical medications?
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
How does your organisation ensure that once a patient’s need for time critical medications is identified, they are prescribed?
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
Who in your patient pathway is responsible for prescribing time critical medications?
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
Who in your patient pathway is responsible for identifying patients who need time critical medications?
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
How does your organisation ensure that patients who need time critical medications are identified as soon as possible on arrival to the ED?
Learning Prompt
Electronic prescribing and medicines administration systems and safe discharge
In acute trusts where digital systems are in place, the prioritisation of medicines reconciliation and medication reviews supports the consistent delivery of these core functions, across seven-day services.
Safety Observation
Electronic prescribing and medicines administration systems and safe discharge
The processes for medicines reconciliation in the community would benefit from being reviewed, taking into account the intent for practice-based pharmacists outlined in NHS England’s Long Term Plan (NHS England, 2019). Summary Care Records
Safety Observation
Electronic prescribing and medicines administration systems and safe discharge
The National Academic Health Science Networks Medicines Optimisation Network has been commissioned by NHS England to support the roll-out of Transfers of Care Around Medicines across England.
Safety Action
Electronic prescribing and medicines administration systems and safe discharge
Counselling of patients newly commenced on a direct oral anticoagulant is critical to the safe use of these medicines. It would be helpful if NHS trusts reviewed this practice paying particular consideration to the communication of changes in medication and …
Safety Observation
Electronic prescribing and medicines administration systems and safe discharge
The practice of documenting only newly prescribed medication on discharge summaries should be reviewed from a patient safety and medicines management perspective.
Safety Observation
Electronic prescribing and medicines administration systems and safe discharge
The use of paper and electronic systems in parallel should be minimised to reduce the risk of error caused by multiple data entry/retrieval sources.
Safety Observation
Electronic prescribing and medicines administration systems and safe discharge
It is recommended that NHS England and NHS Improvement include in the Medication Safety Programme shared decision making and improved patient access to medication information across all sectors of care, to ensure a person-centred approach to safe and effective medicines …
Safety Recommendation
Potential under-recognised risk of harm from the use of propranolol
It is recommended that the National Institute for Health and Care Excellence reviews and updates guidance on the use of propranolol in the treatment of anxiety and migraine, with particular reference to the toxicity of propranolol in overdose.
Safety Recommendation
Potential under-recognised risk of harm from the use of propranolol
It is recommended that the British National Formulary reviews and updates guidance on the use of propranolol in the treatment of anxiety and the advice provided for beta blocker overdose.
Safety Recommendation
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors …
Caring for older patients in hospital often presents a high-risk situation for medication errors occurring. Further efforts should be made to learn from technological developments and the organisation of pharmacy services in other high-risk areas of care that may improve …
Safety Observation
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors …
Clinical pharmacy services should consider using validated tools to assist in prioritising pharmacy care and identifying high-risk medicines and high-risk situations for medication error. Where electronic medical record systems are used, such tools could be integrated into these systems to …
Safety Observation
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors …
Further integration of clinical pharmacy services within the MDT and within strategic decision making may improve a shared understanding of which medicines and situations place patients at greater risk of serious medication errors occurring.
Safety Observation
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors …
Effective clinical pharmacy services have been evidenced to improve a range of measures linked to efficiency and patient safety in acute hospitals.
Safety Observation
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors …
It is recommended that the Royal Pharmaceutical Society, supported by NHS England and NHS Improvement, should provide guidance on models of hospital clinical pharmacy provision. The guidance should provide information on the models’ ability to enhance safety and healthcare resilience …
Safety Recommendation
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors …
It is recommended that the NHS Specialist Pharmacy Service should update its resource on the prioritisation of hospital clinical pharmacy services to facilitate the dissemination of developments in good practice and policy with respect to pharmacy prioritisation and the issues …
Safety Recommendation
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors …
It is recommended that NHS England and NHS Improvement carry out work to understand and further define the work of hospital clinical pharmacy teams, including the period between initial medicine reconciliation and discharge, in consultation with relevant stakeholders.
Safety Recommendation
Procurement, usability and adoption of ‘smart’ infusion pumps
Medicines and Healthcare products Regulatory Agency (MHRA)
Learning Prompt
Procurement, usability and adoption of ‘smart’ infusion pumps
British National Formulary
Learning Prompt
Procurement, usability and adoption of ‘smart’ infusion pumps
Specialist Pharmacy Service • Safe Anaesthesia Liaison Group
Learning Prompt
Procurement, usability and adoption of ‘smart’ infusion pumps
MEDUSA (UK Injectable Medicine Guide)
Learning Prompt
Procurement, usability and adoption of ‘smart’ infusion pumps
A configuration control/management system for drug libraries should be specified within a smart pump safety case.
Safety Observation
Procurement, usability and adoption of ‘smart’ infusion pumps
It is recommended that the MEDUSA (UK Injectable Medicines Guide) advisory board, in conjunction with other relevant multi-professional organisations, develops validated national drug libraries for smart infusion pumps.
Safety Recommendation
Never events: analysis of HSIB's national investigations
Placement of nasogastric tubes (Healthcare Safety Investigation Branch, 2020c).
Learning Prompt
NCEPOD recommendations(22)
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
Blood sodium
Wording not shown. See the report on NCEPOD's website.
Blood sodium
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Juvenile Idiopathic Arthritis
Wording not shown. See the report on NCEPOD's website.
Juvenile Idiopathic Arthritis
Juvenile Idiopathic Arthritis
Wording not shown. See the report on NCEPOD's website.
Juvenile Idiopathic Arthritis
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
CQC inspection actions(690)— showing 50 strongest matches
Nottingham City Hospital
The trust must follow appropriate guidance in the proper and safe storage and administration of medicines, including ensuring fridge temperatures are monitored, recorded and out of range temperatures escalated in line with trust requirements.
Must Do
Nottingham City Hospital
The trust must follow appropriate guidance in the proper and safe storage and administration of medicines, including ensuring fridge temperatures are monitored, recorded and out of range temperatures escalated in line with trust requirements.
Must Do
Wythenshawe Hospital
The service should ensure medicines are stored, checked and managed in line with national and local guidance.
Should Do
Worthing Hospital
The trust must ensure that controlled drug records and the oversight of these are in line with national guidance.
Must Do
Worthing Hospital
The trust must ensure that medicines are used once opened in line with manufacturers guidance.
Must Do
Worthing Hospital
The trust must ensure the proper and safe management of medicine including prescribing systems.
Must Do
William Harvey Hospital
The trust must ensure staff are referencing the same medicine formularies across the CYP departments.
Must Do
William Harvey Hospital
The trust must ensure the appropriate storage of medicines across all medical wards, including escalation areas where medically fit patients reside.
Must Do
William Harvey Hospital
The trust must ensure there is a clinical pharmacy service across all medical wards, including escalation areas where medically fit patients reside.
Must Do
William Harvey Hospital
The trust must ensure there is a clinical pharmacy service across all medical wards, including escalation areas where medically fit patients reside.
Must Do
Westmorland General Hospital
The trust should ensure that systems and processes are established and operated effectively to identify, assess, monitor, escalate and take mitigating actions, particularly in relation to the safest storage of medicine and the checking of emergency resuscitation equipment.
Should Do
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
Westmorland General Hospital
The trust should ensure that the uptake of medicines management e-learning be prioritised to help improve medicines safety.
Should Do
Westmorland General Hospital
The trust must ensure that controlled drugs are safely prescribed, administered, recorded and stored and that registers are correctly and fully completed. The trust must ensure there is a system in place to assess and monitor formal competencies for nursing …
Must Do
Westmorland General Hospital
The trust must ensure that further development and investment in pharmacy resources should be prioritised to make sure medicines reconciliation rates and antimicrobial stewardship are improved across the trust.
Must Do
West Cumberland Hospital
The trust must ensure that controlled drugs and other medications should be stored correctly and securely.Regulation12(1)(2)(g).
Must Do
West Cumberland Hospital
The trust must ensure the timely administration and accurate recording of all medications, including oxygen, prescribed to patients under its care.Regulation(1)(2)(c)(g).
Must Do
West Cumberland Hospital
The trust must ensure that all medicines are stored in accordance with temperature thresholds to ensure efficacy of medication is not impacted upon.Regulation12(1)(2)(g).
Must Do
Wavertree Bungalow
The provider must ensure there is a system in place for the safe management of people's medicines.
Must Do
University Hospital of Hartlepool
The service should ensure that out of date medicines are disposed of in line with the trust's policy.
Should Do
The York Hospital
The trust should consider that doors to rooms where medicines are stored are lockable and kept locked when not in use.
Should Do
The York Hospital
The trust should consider that doors to rooms where medicines are stored are lockable and kept locked when not in use.
Should Do
The York Hospital
The service should review departmental processes for recording of controlled drugs to ensure all documents are completed in line with NICE guidance.
Should Do
The York Hospital
The trust must ensure that controlled substances hazardous to health (COSHH) are always locked away.
Must Do
The York Hospital
The service must ensure all staff are aware of and consistently follow the trust policy to safely store medicines including controlled drugs.
Must Do
The York Hospital
The trust must ensure that the patient's own medicines book is completed on admission and when the medicines are returned to them on discharge.
Must Do
The York Hospital
The trust must ensure that time critical medicines are given when prescribed.
Must Do
The York Hospital
The trust must ensure that controlled substances hazardous to health (COSHH) are always locked away.
Must Do
The York Hospital
The service must ensure all staff are aware of and consistently follow the trust policy to safely store medicines including controlled drugs.
Must Do
The York Hospital
The service must ensure all patients in ED are wearing wristbands at all times for improved safeguarding, security and easier identification when prescribing and administering medications.
Must Do
The York Hospital
The trust must ensure adequate action is taken following audits which identify medication storage issues.
Must Do
The Tunbridge Wells Hospital at Pembury
The service should ensure all medicines are stored and managed safely.
Should Do
The Royal Oldham Hospital
The trust should continue to monitor staff compliance with recording fridge temperatures and consider reminding staff of the need to check with pharmacy when the fridges are not noted to have gone out of range.
Should Do
The Queen Elizabeth Hospital
The service should ensure discarded controlled medicines are recorded in line with trust guidance.
Should Do
The Princess Royal Hospital
The trust should ensure regular medication is prescribed in a timely manner.
Should Do
The Princess Royal Hospital
The service should ensure they introduce a robust way of measuring temperatures for the effective storage of medicines.
Should Do
The Princess Royal Hospital
The service should ensure the storage of medicines within wards are stored safely and securely.
Should Do
The Princess Royal Hospital
The trust must ensure medicines are stored safely and there is oversight and governance processes in place for the safe storage of medicines including but not limited to patients own medicines and effective monitoring of refrigerator temperatures in order to …
Must Do
The County Hospital
The service should improve the safe and proper management of medicines are stored safely and appropriately.
Should Do
The County Hospital
The provider must ensure it is assessing the risks to the health and safety of patients of receiving care or treatment and doing all that is reasonably practicable to mitigate any such risk through carrying out and documenting regular observations, …
Must Do
Sunderland Royal Hospital
The trust must ensure medicines are stored appropriately, and records of medication including controlled drugs, are maintained appropriately.
Must Do
Sunderland Royal Hospital
The trust must implement an effective system to ensure patients receive timely medicines reconciliation.
Must Do
Stroud Maternity Hospital
The service must improve the governance of medicine management. Regulation 12(1)(2)(g).
Must Do
St Richard's Hospital
The trust must ensure that controlled drug records and the oversight of these are in line with national guidance.
Must Do
St Richard's Hospital
The trust must ensure that medicines are used once opened in line with manufacturers guidance.
Must Do
St Albans City Hospital
The trust should ensure medicines are managed in line with guidelines. The trust should ensure that antibiotic prescriptions clearly record review dates and ensure that patients weights are clearly recorded.(Regulation 12).
Should Do
St Albans City Hospital
The trust should ensure that all medicines are stored securely in line with legislation (Regulation 12).
Should Do
St Albans City Hospital
The trust should ensure that patients are weighed to facilitate medication dosing (Regulation 12).
Should Do
South Tyneside District Hospital
The trust must ensure medicines are stored appropriately, and records of medication including controlled drugs, are maintained appropriately.
Must Do
South Tyneside District Hospital
The trust must implement an effective system to ensure patients receive timely medicines reconciliation.
Must Do
PPO death in custody recommendations(17)
The Head of Healthcare
The Head of Healthcare should ensure the local operating policy for managing omitted doses of medication is reviewed and includes more specific and clearer guidance to the Pharmacy Team on the management (including when to alert the GP) of in-possession …
The Head of Healthcare
The Head of Healthcare should rewrite the Medications in Possession document as a Standard Operating Procedure (SOP), which should include: • A system to monitor that a prisoner is taking medications as prescribed. • A medical review to be triggered …
The Head of Healthcare
The Head of Healthcare should ensure that all staff who undertake Medication in Possession Risk Assessments (MIPRA) follow the Spectrum Medicines in Possession policy and review the prisoner’s medical record as part of their assessment.
The Head of Healthcare and the lead pharmacist
The Head of Healthcare and the lead pharmacist should ensure that there is an effective system in place so that prisoners who return to prison late receive their medication.
The Head of Healthcare
The Head of Healthcare should review the treatment policy and management of methadone, including assessing the need for ECG tests when starting methadone and additional monitoring when dosage is significantly increased.
The Head of Healthcare
The Head of Healthcare should investigate why one of Mr Francis’s medications was not prescribed when he arrived at Dovegate and introduce any changes necessary to prevent a recurrence of this issue.
The Head of Healthcare
The Head of Healthcare should review processes to ensure prescribed treatments are effectively administered and issues are promptly resolved.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that prisoners who are not taking or collecting their medication are identified and reviewed, and that prisoners choosing to isolate are able to safely collect and take their medication.
The Head of Healthcare
The Head of Healthcare should establish a system for medication reviews with prisoners who fail to collect their medication on several occasions.
The Head of Healthcare
The Head of Healthcare should ensure that medication in possession arrangements are reviewed and audited so that appropriate safety measures are in place to identify and address non-compliance with medication promptly.
The Governor and Head of Healthcare of HMP Bedford
The Governor and Head of Healthcare should introduce a robust audit process to ensure that when a prisoner is suspected to be under the influence staff understand and follow the protocol.
The Governor and Head of Healthcare of HMP Bedford
The Governor and Head of Healthcare should review whether the current medication administration process is sufficiently robust and identify any weaknesses to minimise the risk of diversion.
The Director of HMP Parc
The Director should ensure that officers supervise medication queues appropriately to limit opportunities for diversion of medication.
The Head of Healthcare
The Head of Healthcare should ensure that when a prisoner does not receive their medication, healthcare staff record the reason on the prisoner’s medications history sheet.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that the relevant risk assessments are undertaken regarding the possession of medication, where a prisoner overdoses.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that pharmacy teams are notified when ACCT procedures are started and that they complete an in-possession medication risk assessment.
The Governor and Head of Healthcare
When ACCT monitoring is started, healthcare staff assess a prisoner’s risk to determine whether he should continue to keep and administer prescribed medication.
IOPC learning recommendations(2)
Care and attention for man whilst detained in custody – Thames Valley …
The IOPC recommends that Thames Valley Police should remind custody officers and medical professionals that its guidance warns against medicating those withdrawing from opiates for six hours after arrival in custody due to any doubt as to what they have …
Recommendation - Suffolk Constabulary, May 2022
The IOPC recommends that Suffolk Constabulary review their custody booking-in procedure to ensure that when two or more detainees are brought into custody with named (boxed) medication, these are separated, booked-in with each respective detainee and recorded on the Custody …
IMB annual reports(10)
Stafford (2021)
This IMB annual report for HMP Stafford, a Category C training prison, covers a period significantly impacted by the Covid-19 pandemic. Key concerns include persistent poor medicines management, deteriorating staff-resident relationships, and the challenges of a highly restrictive regime compounded by a lack of in-cell telephony. Positive aspects noted were low violence and drug levels, successful vaccine rollout, and comprehensive in-cell activity provision.
PRISON
Key concerns
Stafford (2022)
HMP Stafford, a Category C training prison for men convicted of sexual offences, navigated significant challenges during the reporting period, primarily systemic failures in medicines management, Covid-19 outbreaks, and staff shortages impacting the regime. While the Board noted severe concerns regarding healthcare and the lack of in-cell phones, it commended staff resilience, low violence levels, good education attendance, and effective resettlement efforts, particularly in securing accommodation for released residents.
PRISON
Key concerns
North West and Midlands STHF (2023)
The Board has resumed actual visits to most locations, with two exceptions, and consists of three active members who continue their duties robustly, despite being under-strength. Key concerns include the persistent issue of detainees being denied access to prescribed medication in facilities without full-time medical professionals, and the slow rectification of structural and equipment deficiencies. Positive developments include the resolution of airside pass issuance and observations of humane and professional treatment of detainees.
PRISON
Key concerns
North East Midlands, Yorkshire & Humber STHF (2023)
This is the first annual report for the North East Midlands, Yorkshire & Humberside IMB, covering Short-Term Holding Facilities (STHFs) from February 2022 to January 2023. While staff conduct and detainee treatment generally received positive feedback, significant concerns arose regarding the unsafe opening and managing large intakes at Swinderby Residential STHF. The Board also highlighted the critical and unresolved issue of Home Office policy preventing detainees in all STHFs from taking prescribed medication, deeming it inhumane and dangerous.
PRISON
Key concerns
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)
The Scotland and Northern Ireland STHF IMB report highlights generally humane treatment by staff but identifies significant concerns across multiple facilities for the period February 2022 to January 2023. Key issues include the unsafe removal of prescription medication, inadequate disability provisions, and the unsuitability of airport holding rooms for increasingly prolonged detentions. The Board also notes long-overdue building alterations at Larne House and ventilation issues across the estate, urging urgent action from the Home Office and facility managers.
PRISON
Key concerns
Wymott (2021)
HMP Wymott largely maintained safety during a challenging Covid-19 reporting year (June 2020-May 2021), seeing reductions in self-harm and violence. While staff efforts and some initiatives were commendable, the pandemic exacerbated long-standing issues, particularly with healthcare provision, the prison estate's infrastructure, property loss, and complaints handling. The restricted regime severely limited opportunities for purposeful activity, education, and resettlement, causing significant frustration among prisoners.
PRISON
Key concerns
Wandsworth (2021)
HMP Wandsworth operated under severe COVID-19 restrictions for most of the year, leading to prisoners spending up to 23.5 hours a day in cramped cells. The prison remained highly overcrowded and faced significant safety challenges from violence and widespread drug availability. Persistent concerns include the inhumane state of the Victorian buildings, inadequate healthcare facilities, rising mental health needs, and the absence of Home Office immigration support.
PRISON
Key concerns
Thameside (2021)
HMP Thameside operated under a Covid-19 lockdown regime for much of the reporting year, successfully containing the virus but impacting prisoner welfare. The prison transitioned to a restricted regime, and introduced proactive safety management initiatives, including a revised approach to gangs. However, key concerns persist regarding the long-term effects of confinement, delays in mental health transfers, staffing shortages, and insufficient purposeful activity. The IMB also highlights issues with medication dispensing, the healthcare complaints system, and facilities management.
PRISON
Key concerns
Styal (2022)
HMP/YOI Styal successfully managed Covid-19 spread and saw a significant reduction in self-harm, with healthcare and perinatal care provision improving. However, the Board highlighted critical staffing shortages impacting regime and services, persistent decency and fire risks in residential houses, and challenges in managing prisoners with severe mental health needs. Concerns were also raised regarding medication administration, changes to resettlement contracts, and the distress caused by the parcel ban.
PRISON
Key concerns
Thameside (2022)
HMP Thameside, a Category B/C prison, saw its population close to its operational capacity of 1,232. While the regime slowly normalized after Covid restrictions, challenges persisted, including a rise in prisoner-on-prisoner assaults (273 total) despite a decrease in staff assaults (168 total). The Board identified significant concerns around the inhumane delays for mental health transfers (average 39 days), inadequate property handling (complaints up 60%), and the unreliability of the cell bell system. Staff shortages, particularly impacting purposeful activity and resettlement services, were partially mitigated by recruitment efforts, though a large cohort of inexperienced staff remains.
PRISON
Key concerns
IMB individual recommendations(16)
Stafford (2021)
Will HMPPS ensure that HMP Stafford and Practice Plus Group initiate, with immediate effect, a medicines management system that, unlike now, does not impair the safety of its residents and is put under close supervision until ALL previous recommendations (PPO, CQC, HMIP, etc.) have been fully and successfully delivered?
HMPPS
In Progress
Buckley Hall (2021)
Provide secure medication in-cell facilities (6.1.14)
HMPPS
In Progress
Styal (2023)
The Board continues to have concerns around the safe and timely administration and dispensing of medication. What will be done to address the inadequate accommodation for the pharmacy service including the way in which medicines, including methadone, are transported?
HMPPS
Drake Hall (2024)
The Board is concerned about the ongoing problems regarding medication management. This has three components: o The process for administration of medications needs a complete and radical overhaul. o A means of controlling prescription medication needs to be found to reduce the risks associated with trading medications. o The design of the dispensary does not facilitate the effective administration of …
Governor / Director
Berwyn (2020)
Inpatient units/Medication Policy
NHS / Healthcare Provider
Partially Accepted
Berwyn (2020)
Medication Policy issues
NHS / Healthcare Provider
In Progress
Stafford (2022)
Sustained effective healthcare and medicines management that delivers for the residents of HMP Stafford and not just PPG targets
HMPPS
London STHF (2023)
Eaton House and City Airport urgently need a workable solution for administering personal medication. This issue has been raised for many years now.
Other
London STHF (2024)
Eaton House and London City Airport urgently need a workable solution for administering personal medication. This issue has been raised for many years now, including at Ministerial level.
Home Office
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That the administration of detainees’ personal prescribed medication in airport HRs be resolved forthwith.
Home Office
Lewes (2023)
Will the Governor ensure that all prison staff are aware of the importance of supervising dispensary hatches?
Governor / Director
Styal (2025)
What progress is being made to ensure adequate and secure ‘in-possession meds’ lockers in the houses and on the wing?
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2025)
We repeat our recommendation that the policy be immediately revised to allow staff in STHFs to permit the person detained to take a required dose at intervals as per the prescription or pharmaceutical product recommendations. We judge that permitting single doses is important for preventing any risk of health deterioration and for being fair and humane, while minimising any adverse …
Ministry of Justice
London short term holding facilities (STHF) (2025)
Eaton House and London City Airport urgently need a workable solution for administering personal medication. This issue has been raised for many years now, including at Ministerial level.
Ministry of Justice
South and East Short Term Holding Facilities (STHF) (2025)
The Board recommends that the Minister review the accommodation capacity, especially as noted in 4.3 and 5.1 at Luton and Stansted. There are an increasing number of people held overnight at the STHFs, which are not designed for overnight accommodation and, in some places, do not provide a dignified and humane space and where the only hot food available at …
Other
Belmarsh (2025)
Will the Governor continue to work with Practice Plus Group to improve the management and dispensing of medication within the prison?
Governor / Director
In Progress
Health investigations(178)
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xvii)
The Trust should impress upon service users and their General Practitioners the importance of adherence to the prescribed regime of medication.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xvi)
The Trust should devise and operate a system whereby the prescription of all medication for service users is undertaken solely by psychiatrists unless General Practitioner treatment is in accordance with agreed shared care protocols.
london
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 3
The effectiveness of the new medicines management process should be audited to ensure that the system is effective. This should include: an evidence-based audit should be conducted across all five boroughs to provide feedback to prescribing clinicians (Trust and general practice alike) with regard to their prescribing practice; service users …
north_west
Independent investigation report into the care and treatment of Yusuf — Rec 1
We did not see evidence of cannula patency17 having been documented and cannot be assured of the quality of cannulation management. The Trust must ensure that all staff giving antibiotics intravenously check the line is unobstructed before each dose and document regular checks on peripheral IV lines when in situ …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: WPC Nina Mackay, Stratford, London (1997) — Rec 2
The Royal College of General Practitioners, the Royal College of Psychiatrists, the Royal Pharmaceutical Society and the UKCC should issue joint clinical guidance and professional practices on the prescribing, dispensing and monitoring of self-administered medication for people with severe and enduring mental illness. This should include guidance on the implications …
london
Independent investigation: Ryan Walsh, Cheshunt (2008) — Rec 25.4
The EIP Service should take steps to ensure that, when a clinician wishes to prescribe a drug which is unlicensed for the condition for which it is prescribed, the service user’s express consent is obtained concerning the increased risk of side effects. The EIP Service should review and strengthen its …
east_of_england
Independent investigation: Philip Ellison, Preston (2008) — Rec 2
The Trust should complete an annual audit of compliance with medication standards at residential and supported accommodation schemes for which it has management responsibility.
north_west
Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006) — Rec 9
In any case in which there is a known history of non-concordance with medication, specific interventions should be put in place to address that issue.
north_east_yorkshire
Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006) — Rec 8
The trust ought to ensure that the prescribing of anti-psychotic medication accords with NICE guidelines.
north_east_yorkshire
Independent investigation: Michael Kahan, Manchester (2008) — Rec 1
The Trust should ensure that when a patient is suspected of not conforming with Clozapine treatment steps are taken to determine compliance. This should include: Serum/therapeutic level testing; carer involvement/consultation; service user engagement; clinical presentation; mental state examination.
north_west
Independent investigation: Lynda Lovatt, South Shields (2004) — Rec 4
Crisis assessment and treatment service The inquiry was impressed with the crisis assessment and treatment service as and its clinical competence. The inquiry was concerned about some aspects of the prescribing policy whereby doctors could prescribe medication without having seen the patient and considered that for the benefit of all …
north_east_yorkshire
Independent investigation: Laura Sturla, Gillingham (2003) — Rec 9
The trust should review its medication management policy to ensure that all medication prescribed on admission is reviewed by a consultant psychiatrist within 24 hours of admission.
south_east
Independent investigation: Jenny Morrison (s/w), Balham,S London (1998) — Rec 4
The London Borough of Wandsworth urgently review the staffing levels, safety provisions, procedures for supervising medication, and day activity programmes in the residential mental health care homes within the Borough.
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 9
The prescribing and administration of depot anti-psychotic medication in primary care should be reviewed. We suggest the following: (cid:2) Depot medication should normally be prescribed and given by the CMHT (cid:2) Depot medication should not be initiated in primary care (cid:2) If the patient prefers to receive his/her depot medication …
london
Independent investigation: Eileen Cameron, Reading, Berks (1997) — Rec 19
that consideration is given to linking this development with the development of a depot clinic and a lithium clinic.
south_east
Independent investigation: Eileen Cameron, Reading, Berks (1997) — Rec 18
that, in line with the Cambridge model, a. the trust’s pharmacy department takes over control of Clozaril prescriptions, which are limited to 28 days at a time; b. a Clozaril clinic is set up, which is staffed by a dedicated community psychiatric nurse (to assess the patient’s mental state) and …
south_east
Independent investigation into the care and treatment of Mr X — Rec 4
Clinicians should always conduct medication reductions in a systematic manner and guidelines should be developed to support all such decisions. The following should always be considered prior to medication reduction: the role medication has played in the maintenance of recovery; the service user’s mental health response to previous periods of …
X This is the independent investigation report into the care and treatment of Mr X who committed a homicide in 2013. Mr X was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation: Asiya Khatun, Newham (2000) — Rec 18
Newham Primary Care Trust should introduce computer systems to monitor repeat prescriptions; these should be sufficiently sensitive to identify irregularities suggestive of poor compliance or of significant under- or over-use of prescribed medication, and should flag to GPs the necessity for consultation with a patient before a further prescription is …
london
Independent investigation: Asiya Khatun, Newham (2000) — Rec 17
Newham Primary Care Trust, having consulted with the Medical Director of East London and The City Mental Health NHS Trust, should issue advice to GPs through its clinical governance arrangements regarding best practice in the prescription of anti-psychotic medication, updating the advice from time to time. Prescribing patterns should be …
london
Independent investigation: Asiya Khatun, Newham (2000) — Rec 16
Newham Primary Care Trust should review its clinical governance protocols regarding repeat prescriptions to ensure that arrangements for issuing repeat prescriptions include suitable provision for monitoring each patient's condition, and for ensuring that patients who need a further examination or assessment do not receive such prescriptions without being seen by …
london
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 14
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients are fully assessed prior to any change in their medication, and that the assessment includes a full risk assessment, a full social history, and a full medical history.
midlands
Independent investigation: William Moss, Newquay (2007) — Rec 12
The Avon and Wiltshire NHS Partnership Trust should review and audit its prescribing practices, especially with respect to the prescribing of prophylactic and maintenance doses of medication and the regimen for withdrawing medication, to ensure that these comply with Best Practice Guidance
south_west
Independent investigation: Tom Easton, Old St, London (2006) — Rec 4
When patients are with a service for a period of three months or longer, the timely introduction of treatment and medication and the review of dosage and type of medication should be reviewed on a regular basis. This should also be discussed at CPA Meetings.
london
Independent investigation: Stephen O’Brien, Crewe (2016) — Rec 3
The Trust should develop a protocol to support clinicians on when to decide to use depot antipsychotic medication in patients with active psychosis who are unable to dependably use oral antipsychotics.
north_west
Independent investigation: Sandra Crawford, St Albans (2010) — Rec 11
Hertfordshire Partnership NHS Foundation Trust should ensure that clear pathways for the use of medication in the AAU and Accident and Emergency department settings are developed. These should include risk assessment of medication use in all patients including those with medical co-morbidity.
east_of_england
Independent investigation: Roy Warnes, Plymouth (2002) — Rec 1
We recommend that the Trust reviews its policy on the administration of depot injections following test doses and gaps between doses.
south_west
Independent investigation: Rodney Wells, Nottingham (2006) — Rec R2
The trust should review the shared care protocol for atypical antipsychotic drugs to clarify whether patients other than those with diagnoses of schizophrenia and related disorders and bipolar disorder who receive such medication should be subject to the protocol. The review should also consider whether doctors other than the patient’s …
midlands
Independent investigation: Remy Surage (Mr S), Orpington, Kent (1998) — Rec 7.1.2
All circumstances where non-compliance of medication is known or suspected should be reported immediately to the patient’s key worker and consultant psychiatrist. In turn this information should be shared with all staff working with the patient and clearly documented together with an appropriate plan of action.
south_east
Independent investigation: Remy Surage (Mr S), Orpington, Kent (1998) — Rec 7.1.1
Where patients are known to have difficulty in complying with prescribed medication staff should ensure that regular, rigorous and appropriate monitoring of medication takes place and is recorded.
south_east
Independent investigation: Prodip Debnath, Mile End (2010) — Rec Eight
It is recommended that the Trust develops and implements an Objective Structured Clinical Examination (OSCE) framework for the assessment of particular competencies such as observations, medical devices, physical health and medication administration. The further development of Reflective Practice Groups should also be considered.
london
Independent investigation: Prodip Debnath, Mile End (2010) — Rec Four
It is recommended that all transfers of patients should follow a comprehensive protocol that sets out a checklist that is audited on a regular basis to include: Risk analysis and management. Level of Observations. Management Plan. Physical Health. Medication Concordance History. Allocation of Primary Nurse Role. Diagnosis. Health care needs.
london
Independent investigation: Paul Royston Herbert, Brent (2010) — Rec Six
It is recommended that where patients have a pattern of non-concordance with medication that this is reflected in that patient’s care plan and a contingency plan is agreed. It is further recommended that the implementation of this recommendation be monitored by regular audit and reported to the Trust’s Quality and …
london
Independent investigation: Paul BrownDorothy Brown, Liverpool (2014) — Rec 8
An audit of the usage of depot medication in the Secure Division should be carried out and anomalies addressed
north_west
Independent investigation: Paul BrownDorothy Brown, Liverpool (2014) — Rec 7
There should be a Trust wide policy on prescribing high dose antipsychotic medication which includes standards for auditing, which should be in line with the Royal College of Psychiatrists guidelines
north_west
Independent investigation: Ms B, Cheltenham (2008) — Rec 1
The Trust should ensure that there is guidance and training available to staff detailing a consistent approach to manage service users who are not concordant with their prescribed medication and monitor the efficacy of its use by a process of clinical audit.
south_west
Independent investigation: Mohammed Atlas, Birmingham (1997) — Rec 11
The Trust and Primary Care Groups should agree a protocol for establishing ongoing liaison amongst the referring clinician, community mental health teams and the general practitioner to ensure adequate monitoring of the prescribing and dispensing and the taking of medication by patients with mental health problems.
midlands
Independent investigation: Maxine Penfold, Cullompton, Devon (2004) — Rec 1.5
Prescribing practitioners ensure that they clearly record medication regimes and if changes occur, the reasons for it. Ref: Guidance on Good Practice, RPS of Great Britain5.
south_west
Independent investigation: Lucy Ayris, Hayes (2015) — Rec 9
CNWL medicines management group to ensure that all prescribers within the trust are made aware of the Policy in relation to off-licence prescribing.
london
Independent investigation: Lucy Ayris, Hayes (2015) — Rec 1.49
the ‘unlicensed medicines’ and ‘off label’ use’ policy specifically with regards to the use of off-licence prescribing in personality disorder is subjected to audit by the Trust to seek formal assurance of the embeddedness and impact of this action.
london
Independent investigation: Khabi AbreyUnborn Baby, Westcliff (2016) — Rec 2
The Trust, Local Medical Committee and relevant Clinical Commissioning Groups should develop and agree a shared protocol for the administration of depot medication in the community. This should include agreement as to which party is responsible for undertaking the initial patient assessment, and for the initial and ongoing administration of …
east_of_england
Independent investigation: Khabi AbreyUnborn Baby, Westcliff (2016) — Rec 1
The Trust should evaluate the senior primary care mental health nurse practitioner role in south east Essex to establish whether it has facilitated the management of depot medication and mitigated the risk of patients not receiving it.
east_of_england
Independent investigation: Karina Menzies, Cardiff (2012) — Rec 6
Cardiff and Vale University Health Board should assess the possibility of sharing the arrangement introduced by Four Elms Medical Clinic (FEMC) in relation to monitoring the collection of patient prescription medication from their selected pharmacy across the Health Board area; thus ensuring better medication compliance for all conditions.
wales
Independent investigation: John Williams, Camberley (2011) — Rec Recommendation 3
All service users should be monitored for a two-year period following the cessation of antipsychotic medication in accordance with NICE best practice guidance. Secondary and primary care services should develop a protocol as to how this is best managed when service users are discharged back to the care of the …
south_east
Independent investigation: John Williams, Camberley (2011) — Rec Recommendation 2
When service users are ambivalent about their medication and also have a history of medication non-adherence then a medicines management plan should be developed with the assistance of a Pharmacist. This plan should also include: education of the service user and carer (where relevant); the use of service user-led medication …
south_east
Independent investigation: John TaylorBeverley Taylor, Skipton (2021) — Rec 12
The monitoring of Patient E’s medication, efficacy, side effects and his compliance was not adequate. • The Trust must ensure that services users on anti-psychotic medication are monitored at appropriate intervals for side effects using the appropriate methods (e.g. LUNSERS or monitoring blood results) and the services user’s condition is …
north_east_yorkshire
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
Report of a review in respect of: The provision of … — Rec 12
The health board to ensure that patients on medication and who then take their own leave against medical advice, are appropriately supported in their medication needs at the time of discharge.
wales
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: Geraldine Simpson, Birmingham (1997) — Rec 5
the Health Authority and the Primary Care Groups should agree a protocol for the prescribing of anti-psychotic drugs without having a psychiatric assessment or knowledge of the previous medical history.
midlands
Independent investigation: Dorothy Shepherd, Winchcombe (2010) — Rec 2
The Trust should ensure that there is guidance and training available to staff detailing a consistent approach to management service users who are not concordant with their prescribed medication and monitor the efficacy of its use by a process of clinical audit.
south_west
Scottish Fatal Accident Inquiries(6)
Darren Denholm
I recommend that consideration is now given, by the Executive or Parliament if that is required, to the discontinuation of administering general anaesthesia for dental treatment in dental surgeries.
Feb 2000
Isabella Gillies
There will obviously be situations in which it will be inappropriate to weigh a patient due to that patient's condition but in that situation consideration should be given to obtaining the weight from another source, such as earlier hospital records or by reference to the G.P.. I question therefore whether the steps already taken by Fife Health Board go far …
Sep 2005
Jason Ritchie
For the Medical in Possession Policy to be effective and efficient, the prison staff must be alert continuously to the dangers inherent in the self administration of drugs in line with the IP policy. I nonetheless consider that it is a matter that should be, if not already, addressed by the prison authorities.
Oct 2006
Alison Aikman Duguid
Recommendations When officers are advised of the need for medication, they should get it. The system of classification of calls should be more sophisticated and there should be a more sophisticated grading system. Grampian Police themselves are contemplating having five gradings rather than four and that would result from a splitting of Grade 2. The calls in the higher grading …
Jul 2003
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 a learning …
Jun 2010
Stephen Masson
The sheriff having considered the information presented at the Inquiry, in terms of section 26(1)(b) of the Act, in having regard to matters mentioned in section 26(4) of the Act recommends that: (1) A note of all ongoing prescriptions currently prescribed to a patient should be registered with the NHS regardless of the prescriber to allow healthcare professionals immediate access …
Mar 2023
Detention investigations(1)
Independent reviews(6)
Carter NHS Productivity Review — Rec 3
Trusts should, through a Hospital Pharmacy Transformation Programme (HPTP), develop plans by April 2017 to ensure hospital pharmacies achieve their benchmarks such as increasing pharmacist prescribers, e-prescribing and administration, accurate cost coding of medicines and consolidating stock-holding by April 2020, in agreement with NHS Improvement and NHS England so that …
Health & Social Care
Mental Health Taskforce 2016 — Rec 38
By April 2017, HEE should work with the Academy of Medical Royal Colleges to develop standards for all prescribing health professionals that include discussion of the risks and benefits of medication, and take into account people’s personal preferences, including preventative physical health support and the provision of accessible information to …
Health & Social Care
Shaw Detention Review — Rec 49
Recommendation 49: The Home Office and NHS England should promote the self-administration of drugs where risk assessments support that approach.
Immigration
Cass Review — Rec 27
The Department of Health and Social Care should work with the General Pharmaceutical Council to define the dispensing responsibilities of pharmacists of private prescriptions and consider other statutory solutions that would prevent inappropriate overseas prescribing.
Health & Social Care
Accepted
Wessely Review — Rec 7
Decisions about medication should, wherever possible, be in line with the patient's choice and patients should have a right to challenge treatments that do not reflect that choice.
Health & Social Care
Accepted
Cass Review — Rec 8
NHS England should review the policy on masculinising/feminising hormones. The option to provide masculinising/feminising hormones from age 16 is available, but the Review would recommend extreme caution. There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18.
Health & Social Care
Accepted
PHSO casework decisions(45)
P-001367 — Northern Lincolnshire and Goole NHS Foundation Trust
Mr H alleged the Trust covertly gave his mother unsuitable diazepam against her wishes, contributing to her death an hour later by slowing her breathing.
NHS in England
Apr 2022
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-001329 — The Dudley Group NHS Foundation Trust
Mrs O complained about her late husband's rapid deterioration in hospital, alleging incorrect Parkinson's medication, inadequate nutrition/fluid monitoring, and inappropriate use of continence pads.
NHS in England
Mar 2022
P-001589 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Miss W complained a consultant psychiatrist did not warn against antidepressants in a discharge letter and later recommended them, and her GP prescribed them, leading to a psychotic episode.
NHS in England
Partly Upheld
Sep 2022
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-001900 — The Chaseley Trust
Mrs R complained staff administered too much Fucidin cream, failed to administer eye drops correctly, and did not notify her about a hospital appointment.
NHS in England
Mar 2023
P-001863 — Leicestershire Partnership NHS Trust
Ms L complained her mother’s GP failed to visit and delayed end-of-life care and pain relief. She also alleged district nurses improperly gave medication and did not respond to calls.
NHS in England
Mar 2023
P-001894 — Manchester University NHS Foundation Trust
Ms R complained the Trust failed to manage her mother's pain effectively before her death and exhibited poor communication, causing confusion and distress to the family.
NHS in England
Mar 2023
P-002287 — Solent NHS Trust
Mrs M complained Trust staff failed to provide her father with a good supply of syringe driver medication, leading to him dying in pain and causing her family distress.
NHS in England
Upheld
Nov 2023
P-001335 — Oxford Health NHS Foundation Trust
Mr R complained the Trust failed to provide adequate information about olanzapine risks, monitor his weight and bloods, or act on abnormal results, leading to significant weight gain and health issues.
NHS in England
Mar 2022
P-001522 — A medical practice in the Surrey area
Mrs I complained the Practice prescribed tramadol to her mother, Ms H, without examination, despite her medical history, contributing to her death.
NHS in England
Sep 2022
P-003849 — A practice in the Wigan area
A GP practice issued several incorrect prescriptions in October 2022, which could have led to an overdose.
NHS in England
Sep 2023
P-002250 — British Pregnancy Advisory Service
Miss A alleged BPAS gave her abortion medication without proper consultation and provided a dismissive complaint response, causing severe emotional distress. She also claimed misrepresentation and pressure during counselling.
NHS in England
Oct 2023
P-002480 — Manchester University NHS Foundation Trust
Mr C complained the Trust prescribed steroids for an eye condition without informing him of all possible side effects, leading to a mental health episode.
NHS in England
Upheld
Nov 2023
P-002310 — A practice in the Birmingham area
The Practice failed to explain potential side effects of B12 injections, which Mr A believes were unnecessary and caused severe acne and mental distress.
NHS in England
Nov 2023
P-002333 — University Hospitals Birmingham NHS Foundation Trust
Trust allegedly gave inappropriate end-of-life medication and incorrect dosages, wrongly diagnosed a condition, and failed to arrange a promised resolution meeting.
NHS in England
Nov 2023
P-002787 — A practice in the Manchester area
Miss V complained the Practice incorrectly prescribed antibiotics for a cough without examination, resulting in her developing permanent tinnitus.
NHS in England
Jul 2024
P-002764 — West Suffolk NHS Foundation Trust
Mrs C alleged her late husband was inappropriately prescribed a strong anti-psychotic medication (quetiapine), which caused or contributed to his deterioration and death.
NHS in England
Not Upheld
Jul 2024
P-003032 — Surrey and Sussex Healthcare NHS Trust
Mrs A complained she was given the incorrect blood type, had a surgical drain left in her stomach after a C-section, and received an inappropriate voicemail, causing constant pain and job loss.
NHS in England
Oct 2024
P-003516 — Barnsley Hospital NHS Foundation Trust
Mr L complained his wife received inappropriate antibiotics causing an allergic reaction, was not promptly transferred to a specialist unit, deteriorated without response, and had a wrong allergy recorded.
NHS in England
Apr 2025
P-003604 — Frimley Health NHS Foundation Trust
Mrs J complained the Trust mishandled her mother's antibiotics and failed to correctly administer Parkinson's medication, significantly impacting her mother's mobility and recovery.
NHS in England
Jun 2025
P-003706 — Norfolk and Norwich University Hospitals NHS Foundation Trust
Mr L complained the Trust left him without essential eye drops for eight weeks due to errors and failed to advise him on stopping medication as an inpatient, causing stress.
NHS in England
Jul 2025
P-003729 — Portsmouth Hospitals University NHS Trust
Mr O complained the Trust prematurely discharged his wife, mismanaged medication, ignored her broken shoulder, delayed emergency response, and had poor communication, leading to her earlier death.
NHS in England
Upheld
Jul 2025
P-004160 — Mid and South Essex NHS Foundation Trust
Mrs G complained the Trust administered dapagliflozin without monitoring, failed to provide nutrition, and delayed Mr G's bypass surgery, leading to HHS, a heart attack, and his death.
NHS in England
Partly Upheld
Oct 2025
P-004433 — Barts Health NHS Trust
Dr G complained Barts Health did not respect her opinions, lied in medical records, treated her son disrespectfully during transfer, and failed to provide food/medication, leading to fear of hospitals and increased seizures.
NHS in England
Nov 2025
P-001758 — Calderdale and Huddersfield NHS Foundation Trust
Mrs E complained about delays in her father's bladder cancer diagnosis and treatment due to incomplete forms and unacted-upon calls, plus concerns over blood thinner management before surgery.
NHS in England
Jan 2023
P-003901 — North Middlesex University Hospital NHS Trust
Mr A complained the Trust caused his mother's unexpected death on 6 April 2021 by giving her three different medications. He sought an investigation and financial payment.
NHS in England
Jul 2023
P-002285 — A pharmacy in the Greater London area
A pharmacy failed to inform Ms A about changes in thyroxine medication brands, leading to ten months of severe allergic reactions and symptoms.
NHS in England
Nov 2023
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-003071 — University Hospitals of North Midlands NHS Trust
Mrs C complained the Trust inappropriately managed her husband's eating and nausea, insensitively discussed palliative care, administered midazolam, and did not call her before his death, believing this hastened his death.
NHS in England
Oct 2024
P-003495 — East Sussex Healthcare NHS Trust
Miss I complained the Trust failed to operate on her broken wrist, failed to diagnose hip/pelvis fractures, and gave her excessive medication, causing ongoing pain and health issues.
NHS in England
Apr 2025
P-003636 — Manchester University NHS Foundation Trust
Mrs L complained her father was placed in an unobservable ward area, received inappropriate fluids, and was given medication that worsened delirium, contributing to his death.
NHS in England
Partly Upheld
Jun 2025
P-003914 — Maidstone and Tunbridge Wells NHS Trust
Mrs U alleged the Trust caused her husband's death by an overload of IV fluids, rather than pneumonia as stated on his death certificate.
NHS in England
Sep 2025
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.
NHS in England
Nov 2025
P-004422 — Calderdale and Huddersfield NHS Foundation Trust
A wife complained about multiple aspects of her husband's care, including nutrition, medication, ward placement, and communication, impacting his recovery.
NHS in England
Dec 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-003889 — United Lincolnshire Hospitals NHS Trust
Miss A complained her father died from aspiration pneumonia after being given a ham sandwich during a 'fit for discharge' assessment, despite needing a thick liquid diet.
NHS in England
Jul 2023
P-003079 — Guy's and St Thomas' NHS Foundation Trust
Mr P complained about a nurse's mishandling and improper reinsertion of his daughter's tube. He believed this caused her deterioration and avoidable death two days later, leading to extreme distress for his family.
NHS in England
Oct 2024
P-003167 — A practice in the Bradford area
Mrs O complained a GP did not provide a consent form and performed a wrist steroid injection incorrectly, hitting a nerve and causing pain, numbness, and ulcers.
NHS in England
Nov 2024
P-003171 — A practice in the Brent area
Ms F complained about severe shoulder pain and injury (SIRVA) after a tetanus vaccination due to excessive pressure, and the Practice refused to see her.
NHS in England
Nov 2024
P-003633 — Mid Yorkshire Teaching NHS Trust
Miss A complained the Trust failed to diagnose her mother's symptoms, administered incorrect medication, didn't move her to ICU, and didn't clear her mucus, leading to her death.
NHS in England
Jun 2025
P-003608 — University Hospitals of Leicester NHS Trust
Mrs A complained University Hospitals of Leicester NHS Trust failed to operate on her mother-in-law's gallbladder and didn't test for C.diff. She also complained the GP prescribed unavailable medication, assessed by video, and failed to explain end-of-life care.
NHS in England
Jun 2025
P-003620 — Nottingham University Hospitals NHS Trust
Mr F complained Nottingham University Hospitals NHS Trust failed to ensure his aunt's iron infusion was safe, and did not provide appropriate care when she became unwell and deteriorated, leading to her death.
NHS in England
Not Upheld
Jun 2025
P-004070 — Sandwell and West Birmingham Hospitals NHS Trust
Mrs D complained about poor care for her brother, Mr A, including untreated UTI, unsafe discharges, catheter issues, missed epilepsy medication, and lack of learning disabilities nurse support.
NHS in England
Partly Upheld
Sep 2025
P-004439 — The Princess Alexandra Hospital NHS Trust
A man complained about his mother-in-law's care, citing poor hygiene, inadequate investigation of deterioration, mistaken morphine administration, and unsuitable discharge.
NHS in England
Dec 2025
LGO / SPSO decisions(3)
24-006-336 — Promedica24 (Lancashire) Limited
Summary: Mr A complained that the care provider failed to keep his mother Mrs X safe in her home. In particular he complains that the live-in carer was unaware Mrs X had left the house alone in the night, or had put liquid soap in her own food. The evidence …
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2025
21-016-847 — London Borough of Barnet
Summary: Ms X complains about poor care provided to her mother, Ms Y, and poor communication from a Council-commissioned home care provider between June 2021 and February 2022. She said the poor care and poor communication have caused her and her mother distress. The Council was at fault. The care …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
25-002-305 — Sanctuary Care Limited
Summary: We will not investigate Mrs X’s complaint, made on behalf of Mrs Y, about how care home staff dealt with the loss of Mrs Y’s jewellery and changed her carer. Investigation of the jewellery matter would not add to the investigations by the Care Provider and the police nor …
LGO (Local Government & …
Adult Care Services
Aug 2025
Domestic Homicide Reviews(49)
Manchester — recommendation 6
The Manchester CSP, supported by the Health and Wellbeing Board, examines if there are any existing communication strategies in place to support the promotion of the safe disposal of unused medication; In the absence of such strategies, Director of Population Health (MCC) to consider developing a public health message to …
Manchester Community Safety Partnership | Health …
Plymouth — recommendation 21
The perpetrator’s GP to review its prescription policy to ensure it meets national recommendations.
The perpetrator’s GP
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
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
Harlow — recommendation 11.7.4
Compliance with prescribed medication must be based on clinical evidence rather than verbal reassurances, particularly where appointment attendance and other aspects of case management have been uncooperative or resistant.
NEPFT
Plymouth — recommendation 21
The perpetrator’s GP to review its prescription policy to ensure it meets national recommendations.
The perpetrator’s GP
Bridgend — recommendation ABMU MH 7
Care and treatment plans will include details of prescribing and changes in prescription will be recorded in patients’ healthcare records
Abertawe Bro Morgannwg University Health Board
Swansea Bay University Health …
Chorley and South Ribble — recommendation 3
Medication and mail policies to be reviewed and case review completed regarding errors made.
Eaves Lane Surgery
Buckinghamshire — recommendation ORB-5
It is therefore recommended that bloods should ideally be taken prior to commencing Espranor and if not possible then taken a soon as possible after prescribing is initiated.
One Recovery Bucks (Midlands Partnership NHS …
Buckinghamshire — recommendation ORB-4
Keyworker to confirm any medication changes with the prescriber and to record these within the service user/ patients case notes and care plan. Keyworker and other ORB staff who have contact with the service user / patient to observe and monitor for any changes in mental health and to ask …
One Recovery Bucks (Midlands Partnership NHS …
Buckinghamshire — recommendation GP3-2
To review the systems in place that alert the GP Practice to Out of Hours, and vice versa, of each other prescribing and risk monitoring to ensure that there is not over-prescribing, particularly of medication that can lead to addictions.
GP Practice 3
Buckinghamshire — recommendation GP3-1
To develop GP awareness of drug seeking behaviours and ensure that they are alert to the risk of addictions for patients being prescribed opioid medication, considering referrals to One Recovery Bucks before prescribing where there is a history of drug use. If alternative pain relief is not issued, to ensure …
GP Practice 3
Sunderland — recommendation SCCG-3
To promote and monitor implementation of best practice in prescribing management in relation to anti-depressants.
Sunderland Clinical Commissioning Group
Lincoln — recommendation 10.12.1
GPs should be held to account to report cases of attempting to obtain controlled drugs by deception to the accountable officer for controlled drugs. This will be done via NHS England Leicestershire and Lincolnshire area team the CCGs who have a role both to inform and hold GPs to account.
NHS Lincolnshire Primary Care Trust
Brent — recommendation 6.6.2
That when veterans or other clients report at the telephone triage or any point during treatment that they have recently stopped or changed their medication, the resulting changes in symptomatology (eg re-emergence of sleep patterns) should be explored and reviewed with the client and their GP should be made aware …
South West London and St George’s …
South West London and …
Merton — recommendation 2.2
Where it is likely that a family member will administer medication and monitor compliance an assessment should be prioritised and any gaps in understanding about the medication and its risks, resulting from language/educational differences, should be identified and responded to, to ensure that the individual is properly equipped and supported …
South London and Maudsley NHS Foundation …
South London and Maudsley …
Merton — recommendation 1
The SlaM Clinical Policy Working Group commission a discrete Trust-wide policy on clozapine monitoring, management and prescribing. This will help inform local protocols and best practice in both inpatient and community settings. It should include the following based on the learning from this incident: • Titration protocols • Registration with …
South London and Maudsley NHS Foundation …
South London and Maudsley …
Sandwell — recommendation 4
That, in order to improve safe practice and patient care, the Safer Sandwell Partnership asks NHS England, Birmingham, Solihull and Black Country Area Team to remind all GPs practices of the potential risks of repeat prescribing protocols, particularly for patients with mental health issues. To support and inform best practice …
NHS England, Birmingham, Solihull and Black …
Sandwell — recommendation 2
The practice to review their repeat prescribing protocol in respect of antidepressant prescribing to include requirements for periodic medication review to ensure that the patient receives effective treatment.
Sandwell and West Birmingham Clinical Commissioning …
Birmingham Clinical Commissioning Group
Durham — recommendation 10.2.11
Medical information- interpretation of medical conditions / medications and risk, consent Vs honest disclosure.
Durham Constabulary
Durham Constabulary
Colchester — recommendation 4
NHS England and North East Essex Clinical Commissioning Group to further to raise awareness on the potential misuse of prescription drugs particularly Pregabalin and Gabapentin with GP practices and prescribers across Essex including circulation of the Public Health England guidance.
NHS England | North East Essex …
NHS England
Tendring — recommendation 2
The GP surgery should have a clearly documented process in place that identifies medication risk and initiate appropriate and proportionate medication reviews, in accordance to the identified risk and its complexity.
Anglian Community Enterprise
Anglian Community Enterprise
Harrow — recommendation 15
Review Prescribing Guidelines so that they explicitly address pregnancy tests before each new episode of prescribing – including re-titrations.
Compass
Ealing — recommendation 38
When prescribing antiviral medication (such as Peginterferon) which has documented side effects of inducing psychiatric disorders, a specific verification from the patients GP concerning any mental health concerns should be obtained.
Imperial College Healthcare NHS Trust (St …
Leicester — recommendation 1
Reminder to all clinicians about checking medication instructions from outpatient appointments with repeat prescriptions. Investigate any discrepancies.
GP Practice
Leicester — recommendation 14
It is recommended that any change of regime in the administration of depot medication be discussed and agreed with the responsible Consultant.
Leicestershire Partnership NHS Trust
Leicestershire Partnership NHS Trust
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
Bassetlaw — recommendation 7.1
GP practices should ensure that there are robust processes in place for monitoring the collection of prescribed medication and consider the impact of non-concordance of those with caring responsibilities
GP practices
Wiltshire — recommendation 8.5.1
GPs should be reminded re the risk of prescribing amitriptyline when there is a risk of overdose.
Salisbury Plain Health Partnership
St Helens — recommendation 14.3
The panel recommends that the issues regarding drugs dosage and interactions identified by the review (see sections 9.13/14 overview report) are formally reported to GP practice 2 as learning points, and the value of meaningful detailed patient notes, the recording of decisions and rationale be considered as learning points for …
GP practice 1 | GP practice …
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 …
South Cambridgeshire — recommendation 27.17
During the discharge planning process, absolute clarity should be achieved with regard to the arrangements for the provision and administration of medication. (This guidance is to be included in the Q3 “Learning the Lessons’ bulletin of 2019. The Head of Safeguarding and Chief Pharmacist will be the lead managers).
Cambridgeshire and Peterborough NHS Foundation Trust
Cambridgeshire and Peterborough NHS …
South Cambridgeshire — recommendation 27.7
The GP Practice should ensure that an effective policy is in place to address any concerns that a patient may be self-medicating beyond prescribed dosages. Any such policy should include the detail of how and when such concerns may be shared and addressed with other agencies as a means of …
GP practice
Fenland — recommendation 11
A robust process to be established to prevent any delay in the signing of prescriptions and where a capacity concern is identified, there needs to be an escalation process to be able to re-act in a timely manner.
GP Practices
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
Manchester — recommendation 8
The Manchester CSP supports the designated NHS safeguarding teams to liaise with the medicines optimisation teams and GMMH NHS Trust to support best practice across Greater Manchester, and work with MIC to circulate a clear description of best practice to GPs when they are working with patients who transfer from …
Manchester Community Safety Partnership | NHS …
Greater Manchester Mental Health …
Rochford — recommendation 4
Essex Safeguarding Adult Board should be assured that the recommendation from the previous review in the case of Kimmi has clarified the pathways for persons suffering dementia and that there is clear support and review post diagnosis. This should include ensuring clarity in ongoing prescription of medication.
Essex Safeguarding Adult Board
Somerset — recommendation 7.1.3
All referrals into their service for temporary accommodation should be advised to bring identification with them and at least one month’s supply of medication (If medically safe) or a record of the medication in order that support can be ascertained from the new local GP practice for assistance to prevent …
Torbay Domestic Abuse Service
Southend-on-Sea — recommendation 4
All GP practices across SET, should be moving to electronic prescribing which has functionality for prescriptions to be tracked; this should be embedded as a routine check for all claims of lost prescriptions especially for vulnerable patients and drugs that can cause dependency/abuse. (The CCG medicines management team can support …
NHS Southend ICB
Isle of Wight — recommendation 6.13
NHS England and the North Hampshire Clinical Commissioning Group should ensure that primary care providers undertake proactive medication reviews with all patients especially those who have added vulnerabilities or who have demonstrated poor compliance.
NHS England | North Hampshire Clinical …
NHS England
Leicester — recommendation 1
All Health agencies to ensure that staff are cognisant that non-concordance with medication should be considered a trigger for a re-assessment of the risk the patient is to themselves and also to others within the environment the patient is located.
All Health agencies
Leicester — recommendation 2
Make individual risk assessments for patients who do not attend for Shared Care Agreement (SCA) drug physical check and document decisions about continuing to prescribe. Inform secondary care team (if still involved in the patient’s care) of the assessment and decision.
GP Practice
East Sussex — recommendation SPFT3
Ensure that patients that have been de-registered from a GP are supported to re-register and that prescriptions are delivered to a community pharmacy so assurance can be sought re collection.
Sussex Partnership NHS Foundation Trust
Sussex Partnership NHS Trust
East Sussex — recommendation SPFT1
Lack of known and understood legal restrictions gave the perpetrator the choice to disengage with services and decline depot medication. His Care Plan and engagement was reliant on the perpetrator making contact and attending appointments when he was clear that he did not believe that this was necessary, there was …
Sussex Partnership NHS Foundation Trust
Sussex Partnership NHS Trust
Forest of Dean — recommendation 5.2.3a
Ensure that GPs are informed when patients have stopped taking prescribed medication.
Gloucester Health and Care NHS Foundation …
Gloucestershire Health and Care …
Dudley — recommendation 6
Prescribing practice The Panel invites ‘Safe and Sound (the Dudley Community Safety Partnership) to: • Seek assurance from the Pharmacy Clinical Network that systems are in place to support safe and effective prescribing, particularly for drugs that can be abused and/or may lead to dependency
Safe and Sound (the Dudley Community …
Bromley — recommendation 2.1.8
Clinical Directors to discuss and provide guidance to mental health staff about changing medications at the point of discharge. Primary care physicians will be advised to continue on the medication and to seek the support of the community mental health team if a reduction of medications is being considered.
Oxleas NHS Foundation Trust
Oxleas NHS Foundation Trust
Harrow — recommendation 2
Discuss in Leaders Meetings ward meetings and handovers.
Ealing Hospital
Ealing Hospital NHS Trust
Manchester — recommendation 8
That Manchester Community Safety Partnership request Manchester City Council to make use of the new post of GP & Pharmacy Quality and Governance Team Leader to drive improvement in communication between CGL and pharmacies in respect of patients who collect opiate substitute prescriptions and improvement in record keeping by pharmacies.
Manchester Community Safety Partnership | Manchester …
Manchester City Council
CQC enforcement actions(5)
Warning Notice: Mid Essex Hospital Services NHS Trust
The Care Quality Commission (CQC) has told Mid Essex Hospital Services NHS Trust it must make urgent improvements to comply with national standards of quality and safety. This followed an unannounced inspection at Broomfield Hospital in Chelmsford, Essex, which found …
Broomfield Hospital, Chelmsford, Essex
May 2013
Warning Notice: Barnet, Enfield and Haringey Mental Health NHS Trust
The Care Quality Commission has formally warned Barnet, Enfield and Haringey Mental Health NHS Trust that it needs to improve the care it provides to people using its mental health community services. CQC told the trust to make urgent improvements …
May 2014
Urgent Enforcement Action: Birmingham and Solihull Mental Health NHS Foundation Trust
The Care Quality Commission imposed urgent conditions on the registration of Birmingham and Solihull Mental Health NHS Foundation Trust following focused inspections. Inspectors found several concerns, including ligature risks across services and unsafe storage and transport of medicines. The conditions …
Jan 2021
Criminal Prosecution: Sussex Partnership NHS Foundation Trust
The trust admitted failing to provide safe care and treatment to Jamie Osborne, who died on the hospital wing of Lewes Prison in February 2016. The court heard ligature risks were inadequately assessed and prescribed medication was not given. Fined …
£200000
Warning Notice: Leeds Teaching Hospitals NHS Trust
Section 29A warning notice covering maternity and neonatal services at Leeds General Infirmary and St James's University Hospital, following unannounced inspections in December 2024 and January 2025. CQC identified breaches relating to learning from incidents, risk management, the safety of …
Leeds General Infirmary and St James's University…
Jun 2025
MNSI reports(2)
Safety spotlight: Prescribing and dispensing of low molecular weight heparin
Safety spotlight on the prescribing and dispensing of low molecular weight heparin in maternity settings.
Themed Review
Apr 2025
Safety spotlight: Nitrous oxide
Safety spotlight on the use of nitrous oxide in maternity care.
Themed Review
May 2026