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 13 independent accountability sources, so the source mix matters as much as the headline total.
2 inquiry recs
118 PFD reports
3 committee recs
109 HSSIB recs
350 CQC actions
17 PPO recs
2 IOPC recs
16 IMB recs
10 IMB reports
5 Scottish FAIs
1 detention investigation rec
45 PHSO decisions
3 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(2)
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 …
Response Pending
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
Prevention of Future Deaths reports(118)— showing 50 strongest matches
Harold Elvidge
Concerns: A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly in non-critical care settings, necessitating a trust-wide review of fluid management.
Overdue
William Kent
Concerns: Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, compounded by unclear usage instructions.
Overdue
Richard White
Concerns: Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.
Response (700 Club2): The 700 Club clarifies that it does not store or administer medication to clients, emphasizing that responsibility for safeguarding clients regarding medication lies with GPs. They will receive medication if …
Responded
Derrick Rivers
Concerns: The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify these critical issues during inspections.
Overdue
Afifa Qaisar
Concerns: Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating systemic clinical procedural shortcomings.
Overdue
Peter Brookes
Concerns: Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and an unresolved dispensing error causing wrong medication.
Response (University College London Hospitals NHS Foundation Trust): The Trust has a policy that all new patients should have their medication reconciliation completed within 24 hours and are looking to achieve 100% compliance. It also has measures in …
Responded
Edward Devlin
Concerns: Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks of drug trading or stockpiling for overdose.
Response (Care UK): Care UK will develop a formal policy detailing the action required by nursing staff when they are unable to administer medication to a prisoner, for example due to a threat …
Overdue
Donna Kirkland
Concerns: Patients had unlimited and unsupervised access to alcohol-based hand sanitising gels, enabling decanting and storage in rooms. Staff lacked awareness of the gels' alcohol content and potential for ingestion, posing a significant safety risk.
Response (Coventry and Warwickshire Partnership NHS Trust): The Trust replaced wall-mounted alcohol-based hand sanitiser dispensers with alcohol-free alternatives and raised staff awareness of the risks associated with ingestion of alcohol.
Response (Department of Health): The Department of Health acknowledges the concerns and points to existing national guidance on suicide prevention and risk assessment in mental health services, but doesn't describe specific actions taken or …
Responded
Iris Grimwood
Concerns: Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including incorrect medication application and improper use of medical equipment.
Overdue
Marjorie Phillips
Concerns: The patient's fall from a hoist was attributed to the sling's tendency to "bagging" at the sides, creating a fall risk if the patient shifted their weight.
Response: Sunrise Medical Limited states that their instruction manual is a comprehensive document which deals with the issues of purchase; maintenance and operation of equipment supplied by them, therefore no action …
Overdue
Beatrice Gatt
Concerns: A critical antipsychotic medication was not administered due to a transfer error between medication sheets, highlighting a lack of formal training for nursing staff on medication management.
Overdue
Alan Peck
Concerns: Critical medication was not delivered due to an unconnected syringe driver and its subsequent failure to be transferred with the patient, depriving him of essential drugs during transport.
Overdue
Philip Allen
Concerns: The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist advised stopping it, indicating a risk of medication errors.
Response (Eltham Palace Surgery): The practice conducts twice-weekly ward rounds and medication reviews every 3 months by a prescribing advisor and twice a year by the attending clinician, using electronic prescriptions. They have repeatedly …
Responded
Moses McDonald
Concerns: The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a significant safety concern.
Response (South London Maudsley NHS Trust): The Trust updated its physical healthcare policy to outline the responsibility of clinical staff to address patient's physical health needs and made it mandatory that all patients prescribed anti-psychotic medication …
Overdue
Patricia Edge
Concerns: An excessive paracetamol dose was prescribed and dispensed due to inadequate staff training and procedures, compounded by a failure to review the dose or conduct necessary blood tests.
Response (Bolton NHS Trust): Following an investigation, the Trust identified variations in paracetamol prescribing across the organisation, and the Medical Devices Committee and Medications Safety Group have thoroughly reviewed the prescribing process. The Trust …
Overdue
Andrew Aitken
Concerns: Inadequate management of patient's belongings and medication on admission, failure to seek crucial past psychiatric history, and poor discharge planning for a vulnerable patient without a GP.
Response (Barts Health NHS Trust): The Trust investigated the concerns, interviewing staff and reviewing medical records, finding that tablets left at the bedside were intended to be destroyed by a pharmacist and were locked in …
Response (East London NHS Trust): The Trust will ensure staff are aware that patients can self-refer to the RAID service and is considering how to best communicate this information to all staff working in Tower …
Responded
Leonardus Vries
Concerns: Significant documentary failings and lack of audit for non-controlled medication created opportunities for abuse or theft, highlighting a need for improved internal control measures.
Response (Royal Orthopaedic Hospital): The Royal Orthopaedic Hospital reviewed controls around controlled and non-controlled drugs, updated Standard Operating Procedures for Controlled Drugs, conducted audits and found compliance with required standards.
Responded
Darren Linfoot
Concerns: Non-controlled opiate drugs lacked audit, risking them going unaccounted for. Inconsistent methods for patient observations and radio nurse duties indicated a need for standardized training.
Overdue
Laurence Boyens
Concerns: Healthcare professionals appeared to misunderstand guidelines for managing drug dependence in adult prison settings, particularly around monitoring blood pressure before administering methadone or buprenorphine, and some nurses did not know when to withhold medication or escalate concerns.
Response: Following the PFD report, the GMC commenced a review of their earlier decision not to proceed with a complaint about the doctor's care. They have obtained the doctor's comments and …
Response: The Nursing and Midwifery Council acknowledges receipt of the referral and states that it will go through an initial assessment process to determine how to proceed and will then write …
Overdue
Isaac Bahar
Concerns: A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on medication for vulnerable patients.
Response (Brighton and Sussex University Hospitals Trust): Brighton and Sussex University Hospitals Trust has discussed the incident with general surgeons and the nursing and pharmacy teams, leading the general surgeons to decide that codeine should no longer …
Responded
Lottie Reid
Concerns: There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for checking these errors, especially problematic on weekends.
Response (Birmingham Heartlands Hospitals): Birmingham Heartlands Hospital is piloting new documentation within palliative care for clarity of prescribing. Dissemination of information about the Intermediate Care Procedure to all wards at Good Hope Hospital and …
Responded
Geoffrey Parry
Concerns: Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a lack of clear labelling protocols.
Response: The University Health Board has reviewed systems for ECG storage, reinforced the use of the MUSE system, and implemented training on intravenous infusion labelling. The learnings from this incident will …
Responded
Maureen Chatterley
Concerns: Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification of medication quantities and increasing risk of misuse or error.
Response (Bolton NHS Trust): Bolton NHS Trust will introduce a new Wardex for pharmacists to record reviews and develop a local endorsement policy by February 2016. Safe and Secure Handling of Medicines Audits (Duthie) …
Responded
Betty Addison
Concerns: A patient at a care home received five additional, unprescribed Dalteparin injections, with no clear explanation for their source or why they were administered.
Overdue
Derrick Twiate
Concerns: Dispensing pharmacists continue a practice, contrary to professional advice, of snipping tablets from unit dose packs into multi-dose compliance aids, risking drug integrity and patient safety.
Overdue
Michael Hutchence
Concerns: Concerns included frequent, unnecessary ward transfers, poor medical record-keeping, care by unqualified staff, and inaccurate anticoagulant dosing due to weight recording issues. Equipment shortages and non-sterile surgical kits also caused dangerous operational delays and increased DVT risk.
Response (Stockport NHS Trust): The Trust provides context regarding patient transfers and staffing levels, but does not describe specific actions taken or planned in response to the coroner's concerns.
Responded
Daniel Paylor
Concerns: Ambulance services exhibit inadequate regulatory control, safeguards, and auditing for drugs compared to hospitals, lacking sufficient peer supervision and requiring only single-person authority for drug access.
Overdue
Lyndsey Holt
Concerns: Methadone was prescribed unsafely over the phone without a face-to-face consultation, leading to a lack of critical patient information and an inappropriate large supply for a methadone-naive individual.
Overdue
Steven Fone
Concerns: The practice of allowing interchangeable prescription collection by different customers without consent raises concerns about potential abuse, stock-piling, and increased risk of harm or death from medication misuse.
Overdue
Kymberley Holden
Concerns: Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management for neurological patients, pose ongoing risks.
Overdue
Patricia Parker
Concerns: Numerous sedation guidelines are not widely known by clinicians, highlighting a need for better training and awareness of sedation risks, especially in the elderly.
Overdue
Songul Bozdag
Concerns: The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to under-medication, with no systemic safety net.
Response (East London NHS Foundation Trust): The Trust has implemented an inbox-based system to communicate discharge care plans to CMHT staff, and monthly supervision for care coordinators is now working in line with Trust procedures. Regular …
Responded
Jennifer Midgley
Concerns: The drug administration chart fails to clearly distinguish between oral and intravenous paracetamol, lacks patient weight reference for IV dosage, and omits a reminder for weight-modified administration.
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: A lack of clear regulatory guidance on 'red flag' systems for pharmacies to identify patients with similar details and inconsistent chain of custody protocols for controlled drugs pose risks.
Overdue
Ronald Brewer
Concerns: Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.
Response (Barchester Healthcare): A Deputy Manager with palliative care experience was appointed to support training and practice, staff undertook competency assessments, further training was provided, medication fridges were replaced, and policies/procedures were updated. …
Responded
Percy Jacks
Concerns: Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led to poor DVT management.
Response (Welsh Government): Healthcare Inspectorate Wales (HIW) has noted the inquest findings and will use the information to inform their ongoing review of discharge arrangements, focusing on communication and documentation between secondary and …
Response (Rhayader Group Practic): Rhayader Group Practice has implemented a system to record and follow up DVT referrals, inform patients with positive DVT results and prescribe Rivaroxiban, and fast-track medical records for new patients …
Response: Hywel Dda Health Board has streamlined the process for managing potential DVT patients with a direct referral pathway to the Radiology Department, a pre-printed letter from on-call physicians to the …
Response (CQC): CQC had no prior knowledge of the death. They contacted Pencombe Hall care home and Cantilupe Surgery in Herefordshire, reviewed information transfer procedures, and consider their current inspection methodology covers …
Responded
Hayley Sheehan
Concerns: The repeat prescription procedure is unsafe as it relies on manual flagging of early requests, with software unable to automatically identify them. More safeguards are needed, including software adaptation.
Response (The Moat House Surgery): The Moat House Surgery requested changes to the EMIS prescribing process to flag early prescription requests and developed a pop-up box alerting staff to prescriptions issued less than 30 days …
Responded
Carly Gordon
Concerns: The long-term use of shorter-acting benzodiazepines, contrary to guidelines, and a failure to review patients on extended prescriptions risked dependence and adverse outcomes.
Response (Fremington Medical Centre): The practice has sent personal letters to patients on repeat prescriptions for Benzodiazepines asking them to contact the practice for a medication review. The practice has made a commitment not …
Response (Royal College of General Practitioners): The Royal College of General Practitioners provides context on its role, describes its training and membership offerings, and references existing guidance on benzodiazepine prescribing. It supports a joint consensus statement …
Response (NHS England): NHS England will ask its National Clinical Director for mental health and Head of Mental Health and LD Medicines Strategy to write to medical directors and chief pharmacists in mental …
Response (Devon LMC): Devon LMC will remind practices about the review of patients receiving short-acting Benzodiazepines via its electronic newsletter and will make the information available on its website.
Responded
Stuart Walls
Concerns: The patient died from a synergistic toxic effect of multiple prescribed drugs, each within therapeutic range, affecting the central nervous system and respiration. Prescribing practices need to account for cumulative drug interactions.
Overdue
Russell Robb
Concerns: A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding bodies, meant significant police interactions with the deceased were missed, hindering appropriate strategic oversight.
Response (Trafford Safeguarding Board): Greater Manchester Police (GMP) now record high volume callers more accurately, and the GMP function that prioritises and allocates cases now sits within the Partnership Office. A revised policy is …
Responded
Patrick Moran
Concerns: An insulin overdose occurred due to the common practice of using incorrect syringes, exacerbated by the removal of diabetes from mandatory training and the lack of a system to review compliance with safety alerts.
Overdue
David Green
Concerns: The worksite lacked a safe system of work, and there was a widespread practice of employees not wearing seatbelts, with inadequate systems to check compliance.
Overdue
Sandra Miller
Concerns: Urgent action is required to stop unsafe practices with open-ended urinary catheters, establish proper management procedures, and ensure all staff are adequately trained in catheter care.
Overdue
James Quinton
Concerns: Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a verbal prescription, highlighting a lack of essential checking procedures.
Response (Doncaster Bassetlaw Teaching Hospital): Doncaster and Bassetlaw Teaching Hospitals are training individuals as scribes, obtaining a software update for monitors, and have set up a working group with ED and Anaesthetics to explore the …
Responded
Jean Griffiths
Concerns: A national audit revealed widespread poor oxygen prescribing practices in hospitals, with many patients lacking valid prescriptions, risking inappropriate oxygen levels and increased mortality.
Response (Department of Health): The Department of Health acknowledges concerns regarding oxygen prescribing practices. NICE is updating its guideline CG101 to tighten prescribing practice and the BTS and Royal Colleges will have opportunity to …
Responded
Joan Osborne
Concerns: Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response to deteriorating patient condition and insulin refusal.
Response (Adbolton Hall Ltd): Adbolton Hall outlines several actions already implemented, including appointing a new Home Manager, providing diabetes awareness training to staff, purchasing new blood glucose monitoring machines, removing Lucozade from the premises, …
Responded
Barbara Haley
Concerns: Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during meals, contrary to safety assessments.
Overdue
Mike Fell
Concerns: Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some lines lacking essential clamps, creating a risk of accidental opening.
Response (Royal College of Anaesthetists): The RCoA will publish information on central venous access line safety in the Patient Safety Update and include these issues in the updated AAGBI guideline Safe Vascular Access. The FICM …
Response (Barts NHS Trust): Barts NHS Trust has rewritten its policy on the use of central lines and three-way taps, stating that three-way taps should not be used on central lines but self-sealing injection …
Responded
Jonathan Earp
Concerns: Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected illicit drug use.
Response (Gloucestershire Hospitals NHS Trust): The Trust reviewed the circumstances of fentanyl administration, discussed the case with ward staff and presented it to the Senior Nurse and Midwifery Committee. An action plan confirms work undertaken …
Responded
Select committee recommendations(3)
#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 …
Gov response: We acknowledge the significant risk posed by the diversion and misuse of prescription medication within prisons. To prevent this, guidance on supervising medicine queues is already included in Prison Officer Guides, and harm reduction advice …
Partially Accepted
#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 …
Gov response: This Government inherited a system that has been neglected for too long. We are committed to exploring opportunities to make use of technology as we look to develop and support our NHS in line with …
Partially Accepted
#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 …
Gov response: Partially Accept. This Government inherited a system that has been neglected for too long. We are committed to exploring opportunities to make use of technology as we look to develop and support our NHS in …
Response Not Attributed
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
CQC inspection actions(350)— showing 50 strongest matches
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
The Tunbridge Wells Hospital at Pembury
The service should ensure all medicines are stored and managed safely.
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
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
Royal Victoria Infirmary
The service must ensure all staff are aware of and consistently follow the service policy to safely prescribe, administer, record and store and dispose of medicines.
Must Do
Royal Victoria Infirmary
The trust must ensure all staff are aware of and consistently follow the trust policy, systems and processes to safely prescribe, administer, record and store and dispose of medicines.
Must Do
Royal Shrewsbury Hospital
The trust should ensure regular medication is prescribed in a timely manner.
Should Do
Royal Shrewsbury Hospital
The service should introduce a robust way of measuring temperatures for the effective storage of medicines.
Should Do
Royal Shrewsbury Hospital
The service should ensure the storage of medicines within wards are stored safely and securely.
Should Do
Royal Shrewsbury 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
Queen's Hospital
The service should ensure that patients who are self-administering their medications are clearly risk assessed and this is documented, and these patients are identifiable in the ED to staff.
Should Do
Queen's Hospital
The service must ensure that staff follow policy to identify and document patients who are on time critical medicines.
Must Do
Queen Elizabeth The Queen Mother 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
Queen Elizabeth Hospital
The services should ensure appropriate action is taken in a timely manner when fridge temperatures are out of range.
Should Do
Princess Royal Hospital
The trust must ensure that all guidance documents relating to medicines management are up to date.
Must Do
Princess Royal Hospital
The trust must ensure that medicines are stored according to the manufacturer’s instructions.
Must Do
Ormskirk District General Hospital
The service should ensure that records are maintained for all discarded medicine used for epidurals.
Should Do
North Devon District Hospital
The service should ensure medicines are stored, managed, prescribed, and administered safely.
Should Do
Montagu Hospital, Mexborough
ThetrustshouldensureastandardoperatingprocedureisdevelopedforthemanagementofFentanyluseasbolusdoses.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensureastandardoperatingprocedureisavailableforstafftorefertowhenfentanylisdrawnupbystaff.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurethatrefrigeratorchecksareconsistentlyundertakeninlinewithtrustpolicy.
Should Do
Montagu Hospital, Mexborough
Theservicemustimplementaneffectiveprocesstomanage,monitorandrecordtheambienttemperatureofroomswhichstorefluidsandmedication.Regulation17(1)(2)(a)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensuretheproperandsafemanagementofmedicines.Regulation12(2)(g)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensuretheproperandsafemanagementofmedicines.Regulation12(2)(g)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurestafffollowtheproperandsafemanagementofmedicines,andtheserviceusessystemsandprocessestoprescribeandadministermedicinessafely.Regulation12(2)(g)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurethatmedicinesarestoredinsecureenvironmentsandthatallentry/exitandcupboarddoorsarelocked.Regulation12(1)(2)(g)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurethattamperproofsealsandmedicineslistsarepresentinalltheseparateboxesusedforspecificconditions.Regulation12(1)(2)(g)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurethatoxygenisprescribedbyaspecialistpractitionerafteraclinicalreviewanddocumentedontheprescriptionchart.Regulation12(1)(2)(g)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurethatthemissingemergencymedicinefromeachboxisreplaced.Regulation12(1)(2)(g)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensureambientroomtemperaturesaremonitoredandrecordedinallroom’smedicinesarestored.Regulation12(1)(2)(g)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensuretheproperandsafemanagementofmedicines.Regulation12(1)(2)(g)
Must Do
Montagu Hospital, Mexborough
Theservicemustimplementaneffectiveprocesstomanage,monitorandrecordtheambienttemperatureofroomswhichstorefluidsandmedication.Regulation17(1)(2)(a)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensuretheproperandsafemanagementofmedicines.Regulation12(2)(g)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurestafffollowtheproperandsafemanagementofmedicines,andtheserviceusessystemsandprocessestoprescribeandadministermedicinessafely.Regulation12(2)(g)
Must Do
Liverpool Walk in Centre
Ensure care and treatment is provided in a safe way to patients with regard to ensuring there are systems to make sure that documents to authorise medicines are completed.
Must Do
King George Hospital
The service should ensure that patients who are self-administering their medications are clearly risk assessed and this is documented, and these patients are identifiable in the ED to staff.
Should 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
Scottish Fatal Accident Inquiries(5)
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
Detention investigations(1)
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