Alcohol, drug and medication related deaths

Concerns summary A significant delay in securing a mental health bed and conducting an MHA assessment, coupled with the absence of an interim care plan, compromised care for a patient at high risk of falls.

Concerns summary Online medication prescribing allowed applicants to provide false information without verification, leading to excessive and inappropriate prescription of an addictive drug without patient contact or correct guidance.

Concerns summary Concerns include inadequate security of railway platform barriers and a lack of monitoring for a passenger asleep on the platform for an extended period at a 24-hour staffed station.

Concerns summary Large volumes of Oramorph solution, despite containing less than 0.2% morphine, are prescribed without sufficient control. This poses a serious and potentially fatal risk to naive users due to the high total dosage.

Concerns summary Specific synthetic cannabinoid receptor agonists (5F AKB-48, 5F PB-22) are not controlled substances, and the deceased's chronic misuse was not reported to the DVLA.

Concerns summary The absence of clear protocols and an overemphasis on student autonomy led to delayed intervention and reluctance to force entry for a student in distress, risking future deaths.

Concerns summary HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to complacent responses, inadequate treatment plans, and delayed emergency calls for prisoners under the influence.

Concerns summary Concerns about the availability and misuse of dangerous "research chemicals" like MXP, which are freely marketed online, consumed, and pose a life-threatening risk.

Concerns summary Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing related to these checks was deficient.

Concerns summary Product information for SSRI drugs fails to adequately inform prescribers about potential adverse pharmacokinetic interactions with cocaine and other illicit substances, or to advise patients to seek caution.

Concerns summary Easy access to anonymous 'Dark Web' sites for unregulated illicit drugs with unknown potency and content poses a significant and ongoing risk of future deaths.

Concerns summary Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic coma, with resultant trachea injury, directly causing death.

Concerns summary The free availability and high potency/toxicity of the unlicensed 'designer drug' Acetylfentanyl, sold over the internet, poses a significant risk of future deaths.

Concerns summary Readily available and misused synthetic cannabinoids, despite warnings, are dangerous and caused a fatal cardiac event. Concerns were raised about their legal status and control.

Concerns summary Inadequate review of falls risk assessments after repeated falls and patient condition changes was noted. Poor documentation, an insufficient alarm system, and a lack of agency staff training were also concerns.

Concerns summary Inadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering a person in distress.

Concerns summary The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff being unaware of risks and hindering accountability. The "Named Nurse system" was also unclear.

Concerns summary The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk for vulnerable individuals.

Concerns summary The slow process of proscribing the "legal high" MDAI/Gogaine poses a fatal risk, particularly to users with cardiac problems, requiring accelerated action.

Concerns summary A lack of formal 'step-down' policy exists for young people discharged from or failing to engage with Adult Mental Health Services. Additionally, there is insufficient encouragement for insurers to deny cover to establishments selling 'legal highs' linked to mental health issues.

Concerns summary Paramedics lacked awareness that Naloxone's antagonism duration might be shorter than Methadone's respiratory depressant effects, risking patient deaths due to inadequate repeat treatment.

Concerns summary Unsecured, high-dose medication was prescribed to an individual unaware of its dangers, raising concerns about safe prescribing practices for those unable to manage risks.

Concerns summary The drug involved, and several of its chemical compounds, were not fully controlled by legislation, leading to regulatory gaps and potential public health risks.

Concerns summary Lack of basic first aid training among train and station staff prevented the recognition and proper management of a critical medical emergency, specifically airway occlusion.