Alcohol, drug and medication related deaths

Concerns summary Inadequate monitoring and auditing of Sevoflurane stock allowed a bottle to be removed from the hospital unflagged. The trust could not confirm if the drug found originated from their facility.

Concerns summary There is a persistent under-appreciation of the severe risks posed by elevated Propranolol levels, a drug widely prescribed for anxiety, particularly in young people.

Concerns summary Ketamine's Class B classification falsely portrays it as safer than Class A drugs, encouraging illicit use despite causing severe, life-changing health problems like urological and liver damage.

Concerns summary There are concerning delays in transmitting information about prescribed medication from voluntary and NHS organizations to GP surgeries.

Concerns summary A chronic national shortage of mental health beds meant a patient was repeatedly without a bed upon medical discharge, forcing him into unsuitable accommodation or rough sleeping.

Concerns summary Police inappropriately closed a "safe and well" check based on an outdated capacity assessment, demonstrating shortcomings in training and communication with paramedics regarding patients with fluctuating capacity who abscond from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 Systemic failures in medication review led to a patient receiving double the maximum dose for six months. Additionally, inadequate security and search procedures in a mental health hospital allowed illicit drugs to be present.

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 The 'bedroom tax' caused significant housing benefit shortfalls, leading to rent arrears and fear of eviction for a former foster parent, contributing to their fatal overdose.

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 Failures in hospital-to-community pharmacy communication allowed a patient access to morphine after cessation. Additionally, the unregulated online sale of Zopiclone in large quantities presented a significant overdose risk.

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.