Custodial medication interaction warnings
38 items
1 source
Failure to provide clear warnings to prisoners about the critical risks of combining prescribed medications with other substances.
Cross-Source Insight
Custodial medication interaction warnings has been flagged across 1 independent accountability source:
38 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (38)
Rajwinder Singh
Concerns: HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in risk formulation.
Pending
Edward Hands
Concerns: Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, failed recognition of clinical deterioration, and delayed medical assessment.
Pending
Josh Tarrant (3)
Concerns: Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Pending
Aaron Atkinson
Concerns: There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for at least 12 months after initiating antipsychotic medication.
Responded
Abu Rahman
Concerns: Hospital staff experienced frequent Naloxone shortages leading to delayed administration and demonstrated limited awareness of opioid toxicity risks in patients with kidney impairment.
Responded
Chloe Burgess
Concerns: The severe interaction between amitriptyline, paroxetine, and ivabradine is poorly understood, not flagged by prescribing software, and prescribers lack full awareness, posing a significant toxicity risk.
Responded
Thomas Kingston
Concerns: There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing or switching them when ineffective or causing adverse effects.
Responded
Sean Davies
Concerns: Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. Furthermore, some operational support staff lacked proper training or adhered to it.
Overdue
Kevin McDonnell
Concerns: Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain accurate documentary evidence following a death in custody.
Responded
Mohammed Azizi
Concerns: Prison documentation was unreliable, with evidence of forged signatures, retrospective entry of notes, and incomplete disclosure of crucial documents, hindering external investigations.
Responded
Marlin Burrows
Concerns: The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared with medical staff, and there was no joint prison/healthcare oversight.
Responded
Darren Docherty
Concerns: Prisoners released without accommodation are unable to access crucial GP and community mental health services, creating significant risks to their health and safety.
Overdue
Stephen Coster
Concerns: Inadequate prison healthcare assessment, observation, and care planning, coupled with poor communication and prison staff's lack of understanding of emergency transfer protocols, led to significant delays.
Responded
Joy Ebanks
Concerns: Prolonged prescribing of dependency-forming drugs (Oxycodone, Pregabalin) without reduction plans, despite internal guidance on the hazards of long-term use, contributed to toxicity.
Responded
Steven Bowker
Concerns: The prolonged prescription and use of opiate medication pose significant dangers to patients.
Overdue
Susan Gladstone
Concerns: A fatal interaction between tramadol and warfarin occurred due to a lack of warnings for prescribing doctors about this known drug interaction, leading to dangerously high INR levels.
Overdue
Beatrice Dawkins
Concerns: Critical patient allergy information was not accessible or flagged to clinicians, despite being recorded in medical notes, resulting in the inappropriate prescription of a contraindicated medication.
Responded
Sheila Steggles
Concerns: Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and junior staff failing to consult on critical medication interactions.
Responded
Jan Goodliffe
Concerns: Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, which may have contributed to the deceased's death.
Overdue
Ian Miller
Concerns: A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading of prescribed medication, posing a significant risk to prisoner safety.
Overdue
Maria McGauran
Concerns: The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about the patient's excessive use and hoarding of codeine.
Responded
Samantha Gould
Concerns: There is a national gap in guidance for sharing mental health patient care plans and risk information with pharmacies, enabling vulnerable 16-17 year olds to access overdose medication.
Responded
Marlon Watson
Concerns: Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern for managing prisoner welfare and suicide risk.
Responded
Abdeslam Benelghazi
Concerns: Concurrent prescribing of methadone with multiple sedative medications, particularly clonazepam, created a dangerous combined effect of central nervous system and respiratory depression, significantly increasing the risk of sudden death.
Responded
Graham Saffery
Concerns: The BNF, a key GP resource, lacks warnings for co-prescribing amitriptyline and oxycodone, despite other guidance recommending caution and monitoring for this interaction.
Responded
Andrew McCall
Concerns: A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially harmful prescribing of other medications for drug-seeking behavior.
Responded
Marcus McGuire
Concerns: HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not accurately reporting the extent of improvements.
Overdue
Michael Folley
Concerns: The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff training and inconsistent transfer procedures for risk information pose significant safety concerns.
Overdue
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.
Responded
Charles Rendell
Concerns: There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal ideation. This lack of awareness prevents timely recognition and appropriate reaction to potential symptoms.
Responded
Terence Adams
Concerns: Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to follow up on missed appointments contributed to a lack of care.
Overdue
Shalane Blackwood
Concerns: The prison lacks adequate provision for complex health needs, has insufficient staff for prisoner regimes, faces rife NPS use, and has unclear decision-making tools and staff awareness for physical symptoms alongside mental health issues.
Overdue
Devinder Seth
Concerns: Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in orthogeriatric patients, leading to unrecognised opiate toxicity.
Responded
Carl Smith
Concerns: 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.
Overdue
Paul Hardy
Concerns: Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct a Significant Event Analysis.
Overdue
Satheeskumar Mahatheaven
Concerns: Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.
Responded
Stephen Farrar
Responded
Kirk Duboise
Concerns: There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were not reviewed during the reception process.
Pending