Alcohol, drug and medication related deaths

Concerns summary No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a "drug free" wing, missing an opportunity for support and policy enforcement.

Concerns summary A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk that essential medication may not be provided, especially for vulnerable patients.

Concerns summary The lack of speed enforcement on a specific A3083 road stretch has contributed to multiple fatal collisions caused by excessive speeding.

Concerns summary The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the patient self-reporting multiple overdoses and external services raising concerns.

Concerns summary There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice healthcare providers, and no standard, accessible medical records system.

Concerns summary Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked residents not receiving timely medical care.

Concerns summary Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking unobserved and fatal cardiac events in other hospitals.

Concerns summary National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent management of therapeutic excess persists, and new systems risk losing safety nets.

Concerns summary An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence demonstrate a cavalier attitude to patient safety.

Concerns summary Inadequate first aid training for police officers in assessing patient conditions and poor awareness of a dedicated medical advice line led to a failure to recognise severe medical needs.

Concerns summary Police failed to inform the hospital of a patient's release from custody, hindering mental health support efforts. The Metropolitan Police Service also showed no evidence of identifying shortcomings or implementing remediation.

Concerns summary The GP practice lacked a system or policy to ensure appropriate medication reviews for vulnerable patients with addiction or self-harm history, risking stockpiling and misuse of prescribed drugs.

Concerns summary Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines for managing antipsychotic-induced bowel obstruction in emergency departments were identified.

Concerns summary West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing a risk of future deaths.

Concerns summary Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to misleading impressions and hindering proper safeguarding and decision-making.

Concerns summary An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside generally low clinician awareness of the drug's pulmonary risks in the elderly.

Concerns summary Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower risk, leading to increased usage, addiction, and devastating health complications.

Concerns summary A wholesale supplier failed to verify a customer's authorization to distribute medicinal products, leading to bulk sales of paracetamol and ibuprofen to an unauthorized individual, risking future deaths.

Concerns summary Concerns exist about the fatal cardiac side effects of Elvanse, especially with remote prescribing relying on potentially unreliable patient-reported observations and verbal advice that ADHD patients may forget.

Concerns summary An unchecked, open trade in illegal drugs at the festival, combined with a policy that does not eject non-dealing possessors, creates a dangerous market and increases the risk of future drug-related deaths.

Concerns summary The Trust consistently fails to ensure adequate checking and documentation of patient allergy status, leading to ongoing adverse incidents, as current policies and communications are insufficient to embed these critical safety practices.

Concerns summary Police officers failed to follow critical restraint training, including prolonged prone positioning and inadequate welfare monitoring. Officers also did not apply the National Decision Model or challenge inappropriate techniques, contributing to the death.

Concerns summary The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications creates significant safety risks within the prison estate.

Concerns summary The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by preventing comprehensive mental health assessments, despite not altering the outcome in this instance.

Concerns summary The supported living accommodation's policy, which prohibits staff from removing excess medication for safeguarding without resident consent, creates a risk when residents are in mental health crisis.