Alcohol, drug and medication related deaths

Concerns summary Police inappropriately closed a "safe and well" check based on an outdated capacity assessment, demonstrating shortcomings in training and communication with paramedics regarding patients with fluctuating capacity who abscond from treatment.

Concerns summary Police officers lacked crucial training and guidance on responding to drug concealment in the mouth, leading to unsafe interventions and failure to warn suspects of life-threatening choking risks.

Concerns summary Opioid painkillers were prescribed to a patient with a well-documented history of opioid addiction, without sufficient consideration or monitoring of the significant relapse risks.

Concerns summary Concerns were raised about persistent poor record keeping and inadequate communication between professionals within the Trust and with patients.

Concerns summary A pharmacist unilaterally provided multiple advanced doses of a controlled drug, contrary to supervised prescription instructions and without informing the treatment provider, significantly increasing overdose risk.

Concerns summary Incorrect NEWS score calculation and subsequent failure to follow observation protocols led to missed recognition of a deteriorating patient, delaying senior medical review and putting lives at risk.

Concerns summary A patient received toxic and fatal quantities of medication from care home staff through an unknown mechanism, highlighting an unexplained risk of recurring, lethal medication errors.

Concerns summary The Health Board's investigations are consistently of poor quality, ineffective, and untimely, failing to identify and address care omissions or implement learning promptly, leading to recurring patient safety risks.

Concerns summary Clinicians lack a central resource to identify medications increasing suicidal behaviour, call recordings for remote interactions are limited, and there were significant delays in accessing mental health services and medication reviews despite escalating patient distress.

Concerns summary Lack of night-time healthcare in prison means untrained officers manage intoxicated prisoners without clear guidance, compounded by inconsistent information sharing policies between healthcare and prison staff regarding medication and risk.

Concerns summary Insufficient, uncoordinated support and excessively long waiting times (up to seven months) for residential rehabilitation placements put vulnerable patients at significant risk, including sudden death.

Concerns summary Paramedics do not routinely carry flumazenil, an antagonist that could be life-saving in acute circumstances, highlighting a potential gap in emergency medical equipment and protocols.

Concerns summary The GP practice lacked a treatment strategy and policies for long-term opioid prescriptions, including warning flags for addiction risk and guidance on co-prescribing opioids with benzodiazepines.

Concerns summary A patient was discharged with an unrecognised and untreated fractured clavicle, which was also omitted from the discharge summary, leading to delayed care.

Concerns summary Critical drug interaction information recorded in patient notes was not seen or actioned by clinicians due to poor accessibility within the medical records system, impacting patient safety.

Concerns summary Police failed to adequately assess a vulnerable individual, relying on minimal interaction and flawed assumptions about drug use. There was also a lack of follow-up checks and no demonstrable learning or procedural changes post-incident.

Concerns summary There was no protocol to warn patients about critical medication risks with alcohol, and a lack of joined-up communication between acute, mental health, and drug treatment teams hindered safe discharge planning.

Concerns summary Pharmacists lacked guidance for dispensing medication to cognitively impaired patients, leading to identical dosset boxes for cohabiting individuals, which directly contributed to medication mix-ups and posed a safety risk.

Concerns summary Incompatible electronic patient record systems within the same hospital trust led to critical information, such as allergies and renal team entries, not being automatically visible across different sites.

Concerns summary Amitriptyline was prescribed above recommended doses for a contraindicated condition in a dependent patient, with overdose risk unflagged after hospitalisation, and risky monthly prescriptions issued due to inadequate record-keeping and over-reliance on individual doctor knowledge.

Concerns summary Prison CPR guidance, particularly the inclusion of rigor mortis as an exclusion, is inappropriate for untrained staff in non-24-hour healthcare facilities, risking missed opportunities for life-saving resuscitation.

Concerns summary A systemic failure to conduct annual mental health and medication reviews for patients with severe mental illness, alongside a lack of risk assessment and follow-up for deteriorating mental health, created significant safety risks.

Concerns summary A critical lack of formal policies and guidance between CCTV operators and police led to confusion over responsibility for calling emergency services, resulting in dangerous delays.

Concerns summary The absence of residential substance misuse treatment facilities for children under 18 in England places them at increased risk of relapse and overdose by requiring parents to manage complex detoxification at home.

Concerns summary The use of unlicensed door supervisors and misrepresentation of SIA-registered staff roles led to inaccurate safety registers, indicating a systemic failure in security and licensing compliance.