High-risk medication monitoring
Inadequate or absent arrangements for monitoring patients prescribed high-risk medicines, leading to potential harm.
91 items
7 sources
1 inquiry
Source spread
Where this theme appears
High-risk medication monitoring has been flagged across 7 independent accountability sources:
2 inquiry recs
53 PFD reports
4 CQC actions
9 PPO recs
6 patient safety alerts
1 Article 2 learning point
16 PHSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (2)
IBI-7a(ii) — Tranexamic Acid - Scotland, Wales and NI
Recommendation: In Scotland, Wales and Northern Ireland offering the use of tranexamic acid should be considered a treatment of preference in respect of all eligible surgery.
Gov response: Scottish Government The Scottish Government’s Oversight and Assurance Group (OAG) Chair and Deputy Chair wrote to Health Boards in November 2024 asking them to review practice within their Board and confirm that they are offering …
Accepted
No update 2+ yrs
IBI-7a(i) — Transfusion Committees and Tranexamic Acid - England
Recommendation: In England, Hospital Transfusion Committees and transfusion practitioners take steps to ensure that consideration of tranexamic acid be on every hospital surgical checklist; that hospital medical directors be required to report to their boards and the chief executive of their …
Gov response: UK’s governments Recommendation 7 includes an especially complex set of sub recommendations. To ensure a joined up approach across the four nations, experts from across the four nations NHS bodies, blood services and external bodies …
Accepted in Part
No update 2+ yrs
PFD Reports (53) — showing 50 strongest matches
Labhuden Amarshi Vaghadia
Concerns: A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated a lack of professional insight and adequate training.
Response (Leicestershire Partnership NHS): The Partnership NHS Trust reviewed the case, assessed the nurse's competence, and arranged medicines management and emotional resilience training along with additional clinical supervision. They are also implementing a mobile …
Responded
Lucy Kilvert
Concerns: A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a fall, suggesting NICE Guidelines may not sufficiently emphasize the significance of medication in such cases.
Overdue
James Edward Mansfield
Concerns: Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed risks to patient safety.
Overdue
Linda Hudson
Concerns: Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse follow-up visit created significant safety risks.
Overdue
Stephen Ellis
Concerns: A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient hospital monitoring.
Overdue
Bridget Cahill
Concerns: The coroner questions how a patient prescribed morphine can overdose despite receiving less than the prescribed amount, suggesting attention be given to the maximum recommended dose and factors influencing morphine buildup in the body.
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA reviewed the post-mortem report and the pharmacokinetics/dynamics of morphine, concluding that the case does not prompt a review of the maximum permitted dose or a need to adjust …
Responded
Christopher Davies
Concerns: Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning signs of toxicity.
Overdue
Moses McDonald
Concerns: The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a significant safety concern.
Response (South London Maudsley NHS Trust): The Trust updated its physical healthcare policy to outline the responsibility of clinical staff to address patient's physical health needs and made it mandatory that all patients prescribed anti-psychotic medication …
Overdue
Judith Saville
Concerns: Over-prescription of medication to a patient with a history of overdoses was identified. There was a lack of a robust computer system to warn practitioners about overdose history, and an action plan's implementation needed auditing.
Response (Axminster Medical Practice): The practice disagrees that too many Zopiclone pills were prescribed and argues that a special flag highlighting past overdoses would be problematic and potentially offensive. They believe their current assessment …
Response (Devon Partnership NHS Trust): The Trust undertook a Root Cause Analysis Investigation following the death, accepted the recommendations, and completed the identified actions. Assurance that changes have been embedded into clinical practice is monitored …
Responded
Laurence Boyens
Concerns: Healthcare professionals appeared to misunderstand guidelines for managing drug dependence in adult prison settings, particularly around monitoring blood pressure before administering methadone or buprenorphine, and some nurses did not know when to withhold medication or escalate concerns.
Response: Following the PFD report, the GMC commenced a review of their earlier decision not to proceed with a complaint about the doctor's care. They have obtained the doctor's comments and …
Response: The Nursing and Midwifery Council acknowledges receipt of the referral and states that it will go through an initial assessment process to determine how to proceed and will then write …
Overdue
Hana Elhamid
Concerns: 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.
Response (Department of Health): The Department of Health acknowledges concerns and explains existing NICE guidelines for monitoring patients on antipsychotic medication. NHS England is working with the Royal College of Psychiatrists to investigate patient …
Responded
William Bows
Concerns: The report identifies a lack of protocols for advising primary care providers on monitoring patients prescribed Amiodarone, specifically concerning liver function, thyroid tests, and respiratory difficulties.
Response (Sheffield Teaching Hospitals NHS Trust): Sheffield Teaching Hospitals NHS Trust states that an appropriate policy was in place at the time of the prescription of amiodarone and that this was followed during the inpatient stay …
Responded
Thomas Thurling
Concerns: Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a Care Co-ordinator during a period of mental health deterioration due to staff shortages, posed significant risks.
Response (Norfolk and Suffolk NHS Trust): The Trust is sharing the issue of monitoring medication changes with a range of leads, including Pharmacy and those leading Triangle of Care; clinical services have been directed to consider …
Responded
Dorothy Delaney
Concerns: The concurrent prescription of antiplatelet and anticoagulant medications without specialist advice contradicted national guidelines, significantly increasing haemorrhage risk, especially given the patient's amyloid angiopathy.
Overdue
Hireiti Kuflesion
Concerns: Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding of thrombosis risks, resulting in delayed diagnosis.
Overdue
Wayne O’Neill
Concerns: There was inadequate recognition of drug contraindications and dangerous psychotropic medication combinations, with no routine ECG monitoring performed despite expert recommendations, leading to significant risks.
Response: All patients prescribed anti-psychotic medication will receive a routine annual ECG as part of their care; the Lead Pharmacist will sample audit this by 31 January 2016. Training will be …
Responded
Margaret Hions
Concerns: Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.
Response (Margaret Hions): The Health Board has reviewed its practice in the prescribing of tinzaparin and monitoring of blood levels, and a revised guideline has been produced, subject to consultation and approval; the …
Responded
Ann Jacobs
Concerns: There is a lack of consistent 8-hourly potassium level monitoring and adherence to Trust guidance for patients diagnosed with severe hypokalaemia, posing a risk of adverse cardiac events.
Overdue
Marjorie Bassendine
Concerns: Failure to recognise the cardiac risks of multiple psychotropic medications led to a lack of pre-treatment and regular ECGs to monitor for potential QT interval prolongation.
Response (RCPSYCH): The Royal College of Psychiatrists will publicize the coroner's concerns to its members, review continuing medical education initiatives, and inform the Presidents of the Royal Colleges of Physicians and General …
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA reviewed product information for olanzapine, mirtazapine, and indapamide and considers the existing warnings regarding QT prolongation to be appropriate. They are not proposing any regulatory action to change …
Overdue
Michael Mahon
Concerns: The crucial annual clozapine test was missed, and there was no system in place to identify this omission, allowing symptoms undetectable by monthly checks to go unnoticed.
Overdue
Amanda Spark
Concerns: Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential issues with medication management and oversight.
Overdue
Astonn Mitchell-Male
Concerns: The Trust lacks a policy for patient medication monitoring and triangulation of information in community settings, compounded by poor and non-existent record keeping, undermining patient safety.
Overdue
Chand Ali
Concerns: Cyclizine, cautioned for severe heart failure, is routinely administered without individual risk assessment or monitoring of adverse outcomes. There has been no review of alternative antiemetics.
Response (Barts Health NHS Trust): The Trust reviewed the evidence for the caution in the British National Formulary regarding cyclizine use in heart failure patients and found the evidence limited. They will warn teams of …
Responded
Megan Jones
Concerns: A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc recording and when exceeding BNF limits, poses a safety risk.
Overdue
Nathan Cooke
Concerns: There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't attend reviews.
Overdue
Christopher Summerhayes
Concerns: Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible contraindicating familial lipid disorder was not confirmed.
Response: The Health Board reported the death to the Medicines and Healthcare products Regulatory Agency (MHRA). A project proposal is in development by the Mental Health Clinical Board, Pharmacy and Information …
Responded
Liane Davenport
Concerns: There is a need to consider and recommend routine blood level monitoring for patients on long-term, high-dose antipsychotics, especially for older and frailer individuals.
Response (St Nicholas Hospital): The Trust states that the care provided to Ms Davenport was appropriate. They have reviewed HDAT monitoring policy which includes ECG, Urea and electrolytes, Liver function, Prolactin, blood pressure and …
Overdue
Ivan O’Neill
Concerns: Inadequate patient monitoring due to a frail, restless patient being out of sight, combined with an insufficiently sensitive dialysis alarm, delayed detection of a critical bleed.
Overdue
Jamie Poole
Concerns: It is not standard practice across all trusts to regularly test magnesium levels in transplant patients on immunosuppressive medication, despite a known life-threatening side effect, posing an inconsistent risk.
Response (NHS England): NHS England will issue a National Patient Safety Alert (Level 2) on the risk of severe hypomagnesemia in transplant recipients using Tacrolimus and PPIs, and send out a Reminder Alert …
Responded
Ann Coles
Concerns: A significant gap exists in patient oversight as there is no compulsory requirement for lung imaging when individuals are prescribed long-term amiodarone, despite known lung toxicity risks.
Response (Royal College of General Practitioners): The RCGP acknowledges the concerns, provides background on amiodarone, and recommends that the coroner request the MHRA comment on the matter as regulatory responsibility lies with them.
Response (Royal College of Physicians): The RCP recommends that no new monitoring systems are required for amiodarone, but that strict adherence to existing NICE and local shared care guidelines will provide for safe and monitored …
Response (Medicines and Healthcare Products Regulatory Agency): MHRA will take forward the PEAG's recommendations to improve product information on pulmonary toxicity and consider additional risk minimisation measures, such as a Patient Alert Card, and issue a reminder …
Responded
Bruce Houghton
Concerns: The deceased missed an annual medication review, and such reviews fail to inquire about patients' over-the-counter medication use, risking adverse drug interactions.
Response (GMCA): The GMCA will share learning from the case with the Greater Manchester Quality Board, communicate advice and guidance to relevant providers to increase staff awareness, cascade shared learning to professionals …
Response (Uplands Medical Practice): The practice participates in monthly multidisciplinary team meetings. Standardised medication review template will be introduced that includes a prompt to routinely trigger an enquiry as to whether the patient is …
Response (Department of Health Social Care): The response acknowledges the concerns raised and mentions existing guidance and requirements for medication reviews within GP practices and Primary Care Networks, and notes that the Uplands Medical Practice has …
Responded
Steven Allen
Concerns: Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through remote consultations, with insufficient challenge or oversight regarding their chaotic lifestyle.
Response (Stockport Clinical Commissioning Group): Stockport CCG's Medicines Management Team is in discussion with Primary Care Network Leads to explore how the Stockport Integrated Pharmacy Service can support practices in medication reviews for vulnerable patients. …
Responded
Sarah Brady
Concerns: A hospital issued an excessive prescription to a high-risk patient with an overdose history, overriding GP-imposed limits and duplicating medication, which potentially enabled stockpiling and increased the risk of overdose.
Response (Sandwell General Hospital): The hospital disputes that Mrs. Brady was oversupplied with medication, stating that medications were generally supplied for short durations and the dispensed Aspirin was within agreed limits.
Responded
Donald Compton
Concerns: Multiple prescribing and dispensing errors occurred due to an electronic prescribing tool that allowed bypassing allergy checks and a lack of specific knowledge about constituent drugs among prescribers and pharmacists.
Overdue
Malcom Garrett
Concerns: There was no specific guidance for managing or expediting discharge for immunosuppressed patients at high risk of COVID-19. Discharge was also delayed by opiate toxicity, exacerbated by inadequate kidney function monitoring.
Overdue
Eirwen Hollister
Concerns: The GP practice lacked a procedure to prevent further prescriptions after a patient overdose without a mandatory full GP review.
Response (NHS England): Heathview Medical Practice has updated its local policy on management of hospital letters, held a teaching event on read coding, produced a new policy/procedure on patient registrations and deductions, and …
Response (Heathview Medical Practice): Heathview Medical Practice reviewed its overdose policy, provided training, and carried out Docman training; it was also reiterated that clinicians should adhere strictly to the practice's overdose policy.
Overdue
Keith Dimond
Concerns: Significant communication failures led to treating clinicians being unaware of a previous aneurysm diagnosis, resulting in inappropriate treatment. Additionally, patients were discharged on anticoagulants without adequate risk advice, and specialist recommendations were disregarded.
Response (East Kent Hospitals University): East Kent Hospitals University has taken several steps including improving digital record accessibility, emphasizing the importance of clinical history and previous conditions, improving communication regarding patient status and treatment decisions, …
Responded
Evelina Vilkiene
Concerns: The mental health team failed to conduct detailed risk assessments or implement risk management plans during care transitions and medication weaning for a patient at increased self-harm risk, and did not ensure required weekly reviews.
Response (North East London NHS Foundation Trust): The Trust has agreed to take actions to address concerns raised, detailed within an attached action plan.
Responded
Mohammed Hussain
Concerns: The report identifies issues with monitoring clozapine levels, a lack of a safe system to communicate high clozapine levels or effect medication changes, and a lack of understanding of when to measure and how to respond to high clozapine levels; concerns were also raised about pharmacy resourcing and the quality of internal investigations.
Response (Response Birmingham and Solihull Mental Health NHS Foundation Trust): The Trust is developing a specialist Pharmacy Clozapine Team, plans a recorded webinar to improve knowledge around clozapine, and the pharmacy team have prioritised reviewing assay levels and communication to …
Response (Response Medicines Healthcare products Regulatory Agency): The MHRA will continue to keep the issue of monitoring for clozapine toxicity under close review, including reviewing Yellow Card cases and will be writing to the marketing authorisation holders …
Responded
John James
Concerns: A critical lack of an electronic system to alert medical staff when essential anti-coagulation medication is refused or unadministered, significantly increasing the risk of life-threatening venous thrombo-embolism.
Response (Bart Health NHS Trust): The trust will update Millenium training to ensure teams know how to use the flag system to ensure critical medications are not omitted. A medicines safety dashboard is being developed …
Responded
Colin Greenway
Concerns: Incorrect prescribing by junior doctors, inadequate VTE assessments, and consultants' failure to properly supervise prescribing and ensure continuity of patient care were identified.
Response (The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust): The Trust updated VTE guidelines with NICE guidance, introduced mandatory e-learning on VTE, rolled out NEWS2, mandated patient monitoring documentation in Tendable© audits, and implemented a Patient Safety Incident Response …
Responded
Amanda Kramer
Concerns: A patient was prescribed Zoplicone for 18 years without review, despite the drug's short-term license and her high-risk overdose behaviour, raising concerns about medication management.
Response (Wood Street Health Centre): Wood Street Health Centre audited patients prescribed Zopiclone/Zolpidem, is reviewing their medication, has moved to acute prescriptions only (max 2-week supply), instructs 'as required' use on prescriptions, informed local pharmacists, …
Response (North East London NHS Foundation Trust): North East London NHS Foundation Trust (NELFT) audited prescribing practice and revised its prescribing policy for hypnotics, is participating in a working group to improve medication monitoring across primary and …
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges the concerns raised and notes that NHS England is working to support prescribers in managing repeat prescribing; it also acknowledges actions being …
Responded
Teresa Bennett
Concerns: Widespread non-compliance with medication review targets and a lack of standardised review practices led to insufficient patient advice, increasing the risk of inadvertent overdose from combined medications.
Response (Betsi Cadwaladr University Health Board): Betsi Cadwaladr UHB has commenced benchmarking work to identify patients on regular repeat medication without a documented medication review in the last 12-15 months. They will add the Faculty of …
Responded
Malcolm Garrett
Concerns: There was no specific guidance for managing or expediting discharge for high-risk immunosuppressed patients susceptible to Covid-19 in hospital. Additionally, insufficient monitoring and understanding of kidney function led to opiate toxicity.
Response (Department of Health and Social Care): The Department acknowledges the concerns, states that NHS England engaged with the Trust, and that the CQC did not identify a need for further investigation of this specific case but …
Responded
Kelly Stevens
Concerns: A patient on a surgical ward as a medical outlier lacked overall consultant oversight due to absent policy. Doctors failed to monitor electrolytes during IV fluid administration, fluid balance charts were neglected, and outdated care plans were routinely copied and pasted.
Response (Worcestershire Acute Hospitals NHS): WAHT has implemented a daily consultant review of medical outlier patients on surgical wards. The copy forward function on EPR was removed from 3 documents on 14th May 2024: Medical …
Responded
Thomas Burroughs
Concerns: A split Hickman Catheter, posing a significant infection risk, was not removed promptly despite advice and was not reported via the Trust's Datix system as required by protocol.
Response (Mid South Essex NHS Trust): The Trust retrospectively reported a failure to raise an incident on the Datix system for a split Hickman line, identified immediate learning, and cascaded it to staff. Communications have also …
Responded
Laura-Jane Seaman
Concerns: Critical failures in medical record-keeping, delayed patient escalation, non-compliance with major haemorrhage protocols, and misidentification of maternal collapse contributed to the death, highlighting training deficiencies in covert bleeding.
Response (Royal College of Obstetricians and Gynaecologists): The RCOG acknowledges the concerns and emphasises the importance of multidisciplinary training and Trust guidelines aligning with national standards, particularly regarding early warning score protocols and sepsis screening. The College …
Response (Mid South Essex NHS Trust): The Trust has implemented an electronic prescribing and medication administration (EPMA) platform across all sites, improving medication recording and visibility. They have also renewed and improved processes for MNSI investigations, …
Responded
William Northcott
Concerns: Disparities in Clozapine monitoring between specialist clinics and GP practices lead to inadequate patient education on side effects, while guidance also underemphasizes cardiomyopathy risks for this cardiotoxic drug.
Response (Devon ICB): NHS Devon will cascade additional funding to Devon Partnership NHS Trust to support the implementation of more Clozapine clinics to increase capacity. NHS Devon will ensure that outcomes of discussions …
Response (Medicines and Healthcare Projects Regulation Authority): The MHRA acknowledges the concerns and is currently reviewing the product information for clozapine, intending to engage with stakeholders to improve clarity for healthcare professionals and patients, with completion expected …
Response (Devon Partnership NHS Trust): Devon Partnership NHS Trust has set up Clozapine clinics where staff discuss side effects with patients, including additional questions about physical health, palpitations, chest pain, breathlessness, and dizziness. The Trust …
Response (The Pembroke Medical Practice): The practice withdrew from the DPT phlebotomy agreement due to patient safety concerns and highlighted clozapine monitoring at the LMC. They also educated GPs on clozapine side effects and plan …
Responded
Jacqueline Green
Concerns: The hospital failed to adopt national safety recommendations for paracetamol dosage in low-bodyweight patients, leading to overdose risks due to inadequate prescribing alerts, estimated weight entry, and insufficient staff training.
Response (Bedford Hospitals NHS Foundation Trust): The Trust is trialling a live dashboard to monitor patient weight compliance across wards, aiming for completion by the end of 2025, and has purchased a new slide to assist …
Responded
Louise Rosendale
Concerns: The practice failed to conduct sufficient long-term review and oversight of a patient's long-term opiate prescription, despite the associated risks, indicating a lack of detailed planning for such patients.
Response (Flixton Road Medical Centre): Flixton Road Medical Centre details changes made including; reviewing and updating prescribing protocols, implementing mandatory risk-benefit discussions for new or escalated high-level opioid prescriptions, providing staff training in opioid safety …
Response (Greater Manchester Integrated Care): NHS GM outlines planned actions including increased use of the SMASH dashboard, pharmacy reviews of patients flagged by the SMASH opioid indicator, development of standards for primary care review of …
Responded
CQC Inspection Actions (4)
Charlton House Medical Centre
Arrangements for monitoring patients prescribed high risk medicines continued to place patients at risk of harm.
Must Do
Verve Health
The service must ensure that service users undergoing medical detoxification are appropriately monitored during their detox programme, including respiration rates and temperatures.
Must Do
Taplow Manor
The provider must ensure young people receive physical health observations following the use of rapid tranquilisation in accordance with national guidance and the providers policy.
Must Do
Dr Jude's Practice - Riverside & Picton
Continue to monitor and provide evidence of effective medicines reviews for patients on repeat medicines.
Should Do
PPO Death in Custody Recommendations (9)
Manx Care
Manx Care should ensure that patients who come in with complex and high-risk medication (as per the RCGP guidance) have a medication review when they arrive at the prison.
The Head of Healthcare
The Head of Healthcare should ensure that when high or medium risk medications such as amitriptyline are prescribed, the prescriber ensures that a further in-possession risk assessment takes place in line with local and national policy.
The Head of Healthcare
there is an in-possession policy in place, to identify whether a prisoner is able to have weekly or monthly prescriptions in possession which includes vigorous risk assessment, compliance monitoring with the medication regime and random cell checks to count medications.
The Head of Healthcare
there is a system in place to monitor use of glucose tablets and overuse should prompt a diabetic medication review; and
The GP Lead at HMP Exeter
The GP Lead at HMP Exeter should review prescribing processes to ensure high-risk medication assessments are completed in a timely way, with consideration of the impact on the individual
The Head of Healthcare at HMP Wandsworth
The Head of Healthcare should incorporate closer healthcare observations for prisoners who are on a reduction regime and/or are being taken off Gabapentinoids, to monitor withdrawal symptoms and any adverse effects.
The Head of Healthcare
The Head of Healthcare should ensure that the prisoner’s history and risk factors for suicide and self-harm are taken into account in medication in-possession risk assessments.
The Head of Healthcare
The Head of Healthcare should review the treatment policy and management of methadone, including assessing the need for ECG tests when starting methadone and additional monitoring when dosage is significantly increased.
The Head of Healthcare at HMP Wandsworth
The Head of Healthcare should ensure that the prescribers have a face-to-face conversation with a prisoner if there is an intention to reduce or cease any high risk prescribed medication.
National Patient Safety Alerts (6)
Valproate: new regulatory measures for prescribing oversight
Nov 2023
NatPSA/2023/013/MHRA
Risk of oxytocin overdose during labour and childbirth
Sep 2024
NatPSA/2024/010/NHSPS
Reducing risks for transfusion-associated circulatory overload (TACO)
Apr 2024
NatPSA/2024/004/MHRA
Inappropriate dosing risk when switching insulin degludec (Tresiba) products
Dec 2023
NatPSA/2023/016/DHSC
Potential risk of underdosing with calcium gluconate in severe hyperkalaemia
Jun 2023
NatPSA/2023/007/MHRA
Harm from delayed administration of rasburicase for tumour lysis syndrome
Sep 2025
NatPSA/2025/005/NHSPS
PHSO Casework Decisions (16)
P-002632 — Royal Devon University Healthcare NHS Foundation Trust
Mr H complains on behalf of his grandson that the paediatrician did not appropriately manage his medication and there was a lack of leadership in the management of his care.
NHS in England
May 2024
P-002749 — North West Anglia NHS Foundation Trust
Miss U complains the Trust failed to regularly monitor and control her father's iron levels and it failed to give him albumin.
NHS in England
Partly Upheld
Jul 2024
P-003749 — Ashford and St Peter's Hospitals NHS Foundation Trust
Mrs O raised concerns that the Trust failed to follow blood monitoring and medication guidelines for hypothyroidism during her pregnancy. She says the Trust neglected symptoms and scan assessments that might have signalled a miscarriage risk.
NHS in England
Aug 2025
P-004025 — Stockport NHS Foundation Trust
Mrs P complains that the Trust failed to prescribe her husband with blood thinning medication before discharging him from hospital following surgery on 22 October 2024.
NHS in England
Sep 2025
P-004503 — Bedfordshire Hospitals NHS Foundation Trust
Mrs F complains that the Trust did not give her husband, Mr F six-monthly liver follow-ups and did not manage his omeprazole medication properly. Mrs F also complains that staff did not communicate with her about the severity of his condition or let her visit him sooner on the day …
NHS in England
Partly Upheld
Dec 2025
P-001476 — Oxford University Hospitals NHS Foundation Trust
Mr O complains about the care and treatment his wife received following an operation to Mrs O’s right knee. He says the Trust failed to appropriately monitor and manage her diabetes.
NHS in England
Jun 2022
P-001704 — A practice in the Cheshire West and Chester …
Mr L complains the Practice did not properly monitor his father’s blood pressure for two years and wrongly changed his blood pressure medication. He also complains the Practice did not wait for the results of a liver function test before changing a prescription and it did not give appropriate advice …
NHS in England
Partly Upheld
Jan 2023
P-002480 — Manchester University NHS Foundation Trust
Mr C complains that in January 2022 the Trust prescribed steroids for an eye condition but did not tell him about all the possible side effects. He says this meant he was not able to make an informed decision about whether to take the steroids.
NHS in England
Upheld
Nov 2023
P-003495 — East Sussex Healthcare NHS Trust
Miss I complains about the care and treatment she received from the Trust in April 2023 for a broken wrist and hip, and she complains about being over prescribed medication during this same admission.
NHS in England
Apr 2025
P-003648 — Royal Devon University Healthcare NHS Foundation Trust
Mr A has suffered symptoms of his hypothyroidism and believes he has not had support for the level of monitoring and the medication needed to alleviate those symptoms.
NHS in England
Jul 2025
P-004325 — University Hospitals Birmingham NHS Foundation Trust
Mrs E complains the Trust did not treat her pregnancy-induced hypertension during the antenatal period, and did not appropriately monitor her whilst in hospital prior to her planned induction. She also complains the Trust did not administer her epilepsy medication whilst in hospital, and that the Trust performed a sterilisation …
NHS in England
Upheld
Nov 2025
P-001663 — Manchester University NHS Foundation Trust
Mrs R complains the rheumatology team failed to monitor her medication and did not offer any support for managing the side effects. She complains a doctor was dismissive of her symptoms and the Trust took a long time to respond to her complaint.
NHS in England
Dec 2022
P-002906 — North Bristol NHS Trust
Mr U complains the Trust paused giving his wife blood thinners in May 2020 and this led to a blood clot, causing her death.
NHS in England
Aug 2024
P-003221 — University Hospital Southampton NHS Foundation Trust
Mrs F complained the Trust did not manage her father’s warfarin safely and took too long to arrange a CT scan.
NHS in England
Not Upheld
Dec 2024
P-004074 — A practice in the West Berkshire area
Mrs H complains about a Practice in the Newbury area. She says it failed to monitor her brother after prescribing statins, failed to monitor blood pressure and properly investigate recurrent urinary tract infections.
NHS in England
Sep 2025
P-004458 — Birmingham Women's and Children's NHS Foundation Trust
Mr B complains about the care and treatment provided to his son P, who had ADHD and autism, in 2021. He says the Trust did not manage P's ADHD medication appropriately and failed to complete a transition from child to adult mental health services.
NHS in England
Dec 2025