Medication Contamination/Misadministration

Unexplained presence of an allergic medication in a patient's system, raising concerns about contamination or misadministration.

245 items 9 sources 1 inquiry
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Where this theme appears

Medication Contamination/Misadministration has been flagged across 9 independent accountability sources:

1 inquiry rec 29 PFD reports 2 committee recs 3 PPO recs 1 IMB report 47 IMB recs 25 patient safety alerts 128 PHSO decisions 9 LGO/SPSO decisions

When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.

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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.

Frederick Davidson
14 Oct 2013 · Surrey
Concerns: Inadequate note-keeping, inappropriate use of a nasogastric tube given the patient's history, unexplained gaps in clinical notes, communication breakdown between junior doctor and consultant, lack of pneumothorax recognition, premature authorisation of feeding, and delays in X-ray reporting were highlighted.
Overdue
Norma Sheppard
21 Mar 2014 · Staffordshire South
Concerns: The report describes confusion regarding the terms of the deceased's discharge from hospital to the care home, specifically regarding the provision of sub-cutaneous fluids, which presented difficulties in finding a suitable placement.
Overdue
Michael Anthony
09 Apr 2014 · London (Inner South)
Concerns: The coroner noted that the deceased's Gabapentin level was five times the normal therapeutic level, the reason for which was undetermined, and that the drug is usually not prescribed in diabetics due to the risk of severe reaction.
Response (Guys St Thomas NHS Trust): The trust has built a review of the case into their day to day practice and reported the case via the MHRA yellow card reporting system. The trust has also …
Overdue
Jessica Bond
30 Jun 2014 · Essex
Concerns: Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine rupture and associated complications.
Overdue
Alan Peck
14 Oct 2014 · Manchester (South)
Concerns: Critical medication was not delivered due to an unconnected syringe driver and its subsequent failure to be transferred with the patient, depriving him of essential drugs during transport.
Overdue
Elsie Mallalieu
17 Nov 2014 · Manchester (South)
Concerns: Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR decision, hindering escalation for treatable infection.
Response (Tameside Hospital NHS Trust): Tameside Hospital NHS Trust provided training to doctors in the Orthopaedic Department regarding patient transfer protocols and the involvement of senior medical staff. The training also forms part of the …
Responded
Marjorie Ellery
26 Nov 2014 · Surrey
Concerns: Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent obtained for this treatment was not informed consent.
Response (Frimley Health NHS Trust): The Trust now requires registrar or higher authorisation and documented discussion with the patient for medication prescriptions when allergies are known. A new policy on allergy management is being developed …
Responded
Annette Charlton
09 Jan 2015 · Birmingham & Solihull
Concerns: Pharmaceutical manufacturers are producing medications in almost identical packaging, which significantly increases the risk of dispensing errors and poses a serious threat to patient safety.
Response (Crescent Pharma Limted): Crescent Pharma has scheduled a meeting with the MHRA to discuss packaging redesign and the use of colour to differentiate products and strengths, after their request to do so in …
Overdue
Lydia Corah
11 May 2015 · Nottinghamshire
Concerns: An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, and adversely affecting the intended patient.
Response: Enhanced induction training has been implemented to reduce patient identification errors. The RCA generated an action plan that included reflection by the member of staff involved and updating of checking …
Responded
Sneh Chaudhry
15 Jun 2018 · London (West)
Concerns: Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a risk of administering the wrong, more toxic medication.
Overdue
Marie Millward-Winter
15 Jan 2019 · Manchester (City)
Concerns: Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and contributed to death.
Response (North West Ambulance Service NHS Trust): The Ambulance Service argues the Regulation 28 report was issued prematurely because they were not notified of the inquest date or granted Interested Person status. They maintain the EMT acted …
Overdue
Gabriele Kreichgauer
22 Feb 2019 · London Inner (South)
Concerns: The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource led to ineffective treatment. The resource also lacked a clinician feedback mechanism for inaccuracies.
Overdue
KennethDaly
23 Oct 2019 · London Inner (North)
Concerns: Unclear advice from consultants regarding co-prescribing multiple opioids and a lack of tailored written guidance for patients on the risks of combined opioid use were identified.
Overdue
Doris Clark
19 Dec 2019 · London (East)
Concerns: A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), risking opiate overdose. Lack of standardised units between services creates a significant safety concern.
Overdue
Colin Beaumont
19 Dec 2019 · Warwickshire
Concerns: A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to their death.
Response (South Warwickshire NHS Foundation Trust): The Trust will amend its Nasogastric Tube Insertion policy to mandate review of alternative feeding options after two unsuccessful attempts, will arrange a Grand Round discussion on balancing clinical risks …
Responded
Ashley Walker
31 Jan 2020 · Warwickshire
Concerns: A communication error confused ingestion with a spillage, and an effective antidote (methylene blue) for toxicity was not available on the ambulance.
Response (West Midlands Ambulance Service): Following a communication error, WMAS has instructed all staff to remove the WISER app from work devices unless trained. They have also produced further guidance in relation to Individual Chemical …
Responded
Jerome Peat
08 Feb 2021 · Avon
Concerns: A computer system failure at the GP surgery led to duplicated morphine prescriptions, causing the deceased to receive significantly more medication than intended and resulting in an overdose.
Overdue
Michele Duckworth
12 Feb 2021 · Stoke-on-Trent & North Staffordshire Coroner’s Court
Concerns: The patient was incorrectly prescribed Tazocin, an antibiotic against trust guidelines due to prior ESBL colonization, an error that was repeatedly missed during medical reviews.
Overdue
Ian Hall
14 Jun 2021 · Greater Manchester South
Concerns: Incorrect medication was dispensed, and pharmacies lack checks to prevent vulnerable adults, whose non-clinical carers administer medications, from receiving wrong prescriptions.
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA will review the packaging of the amitriptyline and atenolol medicines and if improvements could be made they will contact the pharmaceutical manufacturers who supply these medicines and seek …
Overdue
John Skinner
10 Feb 2022 · Hertfordshire
Concerns: A significant medication overdose resulted from a junior doctor mishearing a verbal dosage instruction, highlighting a foreseeable communication risk when numbers are expressed orally in clinical settings.
Overdue
Lily Girton
11 Aug 2022 · East London
Concerns: Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, hindering timely care access. The care plan was not updated despite escalating hospital concerns, leaving the patient without necessary support.
Overdue
Anita Graves
20 Jun 2023 · Manchester South
Concerns: The visual similarity of carbimazole tablets of varying strengths, and to aspirin, creates an overdose risk. The community dispensing process fails to mitigate this danger, potentially exacerbating the risk.
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA has sought advice from the DHSC, GPhC and RPS and describes planned changes to medicine packaging and dispensing, including the introduction of mandatory Patient Information Leaflets and monitoring …
Responded
Rachel Edwards
27 Feb 2017 · Suffolk
Concerns: The report notes Rachel was informally admitted.
Response (Norfolk and Suffolk NHS Foundation Trust): The Trust will assess medications prescribed upon discharge, which will continue across the Trust. The Trust is planning the technical changes required to build electronic bridges between different elements of …
Responded
Paul Holmes
27 Jun 2024 · Cornwall and the Isles of Scilly
Concerns: Poor communication, lack of direct doctor-to-doctor handover, and unrecorded treatment plans during hospital transfer led to delayed administration of crucial intravenous fluids.
Overdue
David Martin
08 Oct 2024 · Cornwall and the Isles of Scilly
Concerns: A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, even after a senior nurse recognised the oversight.
Response (Royal Cornwall Hospitals): The Trust has reviewed and amended the wording in the PCI pack to clarify Dual Anti-Platelet Therapy provision, with changes approved by the Safer Surgery Group and Forms Review Group. …
Responded
Susan Young
24 Jun 2025 · Norfolk
Concerns: Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, creating a risk of further overdose.
Response (James Paget University NHS Foundation Trust): The James Paget University Hospital NHS Foundation Trust updated the Trust Transfer Policy, communicated policy expectations to ED staff, provided associated staff training and implemented an ED Patient Handover Form, …
Response (James Paget University Hospitals NHS Foundation Trust): The James Paget University Hospital NHS Foundation Trust updated the Trust Transfer Policy, communicated policy expectations to ED staff, provided associated staff training and implemented an ED Patient Handover Form, …
Responded
Aaron Atkinson
30 Jun 2025 · Derby and Derbyshire
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.
Response (National Institute for Health and Care Excellence): NICE clarifies that the Clinical Knowledge Summaries (CKS) are not NICE guidance, and that NICE guidance and prescribing information for risperidone does not include a requirement for continued ECG monitoring. …
Response (NHS Derby and Derbyshire Integrated Care Board): The ICB will review the investigation from the practice, await the NICE response, update the JAPC guideline and medicines management webpage, and share lessons learned and guidance updates with primary …
Responded
Dominic Philip
· Northamptonshire
Concerns: The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns about medication contamination or poor stock control.
Response (Medicines Healthcare Products Regulatory Agency): The MHRA explains that there is no standardised test for contrast medium allergy, that lidocaine is a prescription-only medicine but not a controlled drug (and thus local hospital policies determine …
Response (The Royal College of Radiologists): The RCR has established a working party to develop new iodinated contrast medium (ICM) and gadolinium guidelines, anticipated for publication in early 2026. They also provide general observations on allergy …
Response (University Hospitals of Northamptonshire NHS Group): The Trust states there is no reliable or standardised test to predict contrast reactions in patients without prior symptoms and that life-threatening reactions are rare. They confirm no national alerts …
Response (Department for Health and Social Care): The Department for Health and Social Care acknowledges the concerns but defers direct response to other agencies, providing existing information from NHS England on the safe and secure handling of …
Responded
Sidra Aliabase
21 Jan 2026 · Inner West London
Concerns: Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and a significant delay in recognizing and treating subsequent hypocalcaemia.
Response (Great Ormond Street Hospital for Children NHS Foundation Trust): • Great Ormond Street Hospital NHS Foundation Trust has reviewed its current on-call paediatric cardiology service to identify and implement the necessary actions to ensure that patients like Sidra are …
Overdue
Drake Hall (2024)
The Board is concerned about the ongoing problems regarding medication management. This has three components: o The process for administration of medications needs a complete and radical overhaul. o A means of controlling prescription medication needs to be found to reduce the risks associated with trading medications. o The design of the dispensary does not facilitate the effective administration of …
Governor / Director
Berwyn (2020)
Inpatient units/Medication Policy
NHS / Healthcare Provider
Berwyn (2020)
Medication Policy issues
NHS / Healthcare Provider
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That the administration of detainees’ personal prescribed medication in airport HRs be resolved forthwith.
Home Office
Bedford (2021)
There are issues around the dispensing of medication that need resolving. Some prisoners are not receiving their medication, while others may be selling it on, as there has been inadequate supervision at the pharmacy.
Governor / Director
Styal (2023)
The timely administration of medicines and the inadequate dispensing facilities remain a significant concern – how will this be addressed in the future?
Governor / Director
North West and Midlands STHF (2023)
For the fifth year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detained individuals with access to their prescribed medication. The Board continues to note that the welfare of detained individuals has been adversely affected by this situation. This occurs particularly in holding rooms and …
Ministry of Justice
North East Midlands, Yorkshire & Humber STHF (2023)
We recommend that Home Office policy be immediately amended to enable staff in STHFs to continue removing medicine from the possession of those detained but to allow them to permit the person detained to take a required dose at intervals as per the prescription or pharmaceutical product recommendations. We judge that permitting single doses is important for preventing any risk …
Home Office
Hollesley Bay (2023)
A review of the arrangements for dispensing medication is requested. The current regime is slow and cumbersome, which causes frustration for prisoners and friction with healthcare staff.
Governor / Director
Forest Bank (2024)
The Board has received complaints about medication treatment dispensing times being missed frequently, which has an impact on prisoners’ health. What action will the prison take to improve this outcome?
Governor / Director
Stafford (2020)
Will the Governor Ensure that the orders already issued regarding the supervision of medicine queues are adhered to at all times
Governor / Director
Oakwood (2020)
The Director should ensure that officers are present at the medicine hatches during the dispensing of medication.
Governor / Director
Elmley (2020)
The Board seeks reassurance that the healthcare department’s attempts at auditing the issue of paracetamol by prison staff on the wings is supported by managers. Given the near-miss this year, it is important that paracetamol is controlled in similar ways to any other medication provided in the prison.
Governor / Director
Stafford (2021)
Will HMPPS ensure that HMP Stafford and Practice Plus Group initiate, with immediate effect, a medicines management system that, unlike now, does not impair the safety of its residents and is put under close supervision until ALL previous recommendations (PPO, CQC, HMIP, etc.) have been fully and successfully delivered?
HMPPS
Scotland and Northern Ireland Short-Term Holding Facilities (2022)
We would urge the Minister to request that the Home Office carry out an urgent assessment of the risks to detained people as a result of the removal of their prescription medications. These risks should then be taken into account when designing a practical strategy for ensuring that detained people receive their appropriate medication. The desired outcome would be that …
Other
North and Midlands Short Term Holding Facilities (2022)
For the fourth year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detained individuals with access to their prescribed medication. The Board continues to note that the welfare of detained individuals has been adversely affected by this situation. This occurs particularly in holding rooms and …
Home Office
Wandsworth (2023)
Non delivery of medications has been a major concern to the Board this year. What is being done to ensure that this improves?
Governor / Director
Styal (2023)
The Board continues to have concerns around the safe and timely administration and dispensing of medication. What will be done to address the inadequate accommodation for the pharmacy service including the way in which medicines, including methadone, are transported?
HMPPS
Lewes (2023)
Will the Governor ensure that all prison staff are aware of the importance of supervising dispensary hatches?
Governor / Director
Wandsworth (2024)
Non delivery of medications has been a major concern to the Board this year. What is being done to ensure that this improves?
Governor / Director
Hollesley Bay (2024)
A review of the arrangements for dispensing medication is requested. The current regime is slow and cumbersome, which leads to frustration among prisoners and friction with healthcare staff.
Governor / Director
Feltham (2024)
When will the Traka units for dispensing medication be commissioned for use?
Governor / Director
Cardiff (2024)
The Board again wishes to highlight applications about medication/ prescriptions continue to be received at a very high level and recommends further consideration be given to addressing this.
NHS / Healthcare Provider
Bronzefield (2024)
What plans does the prison have to work more effectively with CNWL and Forward Trust to improve the timely dispensation of medication? (6.1)
Governor / Director
Send (2025)
Poor communication has led to delays in the provision of medication to newly arrived prisoners (6.1).
HMPPS
Berwyn (2025)
If prisoners arrive late on Fridays, the pharmacist will not be available until the Monday. This is a major issue, as it means that medication cannot be dispensed over the weekend.
HMPPS
Heathrow Short Term Holding Facility (2020)
The Home Office should ensure that the new system is provided as quickly as possible to ensure that people in detention can access their own prescription medication and common non-prescription medication (paras. 9.2 - 9.5; 18.2 – 18.3; 26.2; 34.2).
Home Office
Durham (2020)
Why are incidents of prisoners missing three consecutive days of medication no longer reported?
Governor / Director
Wayland (2022)
The Board suggests there may be a need to review how the medication periods are managed and supervised, especially considering instances of violence in the drug dependency medications queue and policy of prescription reduction.
Governor / Director
Gatwick, Stansted, Luton and Lunar House (2022)
As stated above, at Gatwick, Luton, and Stansted airports, dedicated medical practitioners should be available, on a 24/7 basis to, where appropriate, authorise the taking of their own medication by detained individuals, or where there is an urgent need, to prescribe medication.
NHS / Healthcare Provider
Gatwick, Stansted, Luton and Lunar House (2022)
at Gatwick, Luton, and Stansted airports, dedicated medical practitioners should be available, on a 24/7 basis to, where appropriate, authorise the taking of their own medication by detained individuals, or where there is an urgent need, to prescribe medication.
Other
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)
The Minister is urged to request that the Home Office carry out an urgent assessment of the risks to detained people as a result of the removal of their prescription medications. These risks should then be taken into account when designing a practical strategy for ensuring that detained people receive their appropriate medication. The desired outcome would be that the …
Other
Rye Hill (2023)
The Board is concerned that processes designed to ensure prisoners have sufficient prescribed medication with them when transferring to Rye Hill are not being consistently applied across the prison estate.
HMPPS
Featherstone (2023)
Issues with low numbers of healthcare staff have, on occasion, meant that the regime has been disrupted because of delays dispensing medication. This has been an ongoing issue and consideration should be given as to whether the system can be changed to increase its reliability and consistency.
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2024)
We repeat our recommendation that the policy be immediately revised to allow staff in STHFs to permit the person detained to take a required dose at intervals as per the prescription or pharmaceutical product recommendations. We judge that permitting single doses is important for preventing any risk of health deterioration and for being fair and humane, while minimising any adverse …
Home Office
Featherstone (2024)
Issues with low numbers of healthcare staff have, on occasion, meant that the regime has been disrupted because of delays dispensing medication. This has been an ongoing issue and consideration should be given as to whether the system can be changed to increase its reliability and consistency.
Governor / Director
Wymott (2025)
The report raises a number of concerns about the delivery of medication and essential repairs to the fabric of the prison. What will the Governor do to ensure that the service provided by external agencies (such as Practice Plus Group, Amey) is of an acceptable standard?
Governor / Director
Durham (2025)
The Board has observed the lack of supervision of medication queues throughout the year. How will the Governor ensure that staff are deployed to maintain adequate supervision?
Governor / Director
Durham (2025)
The Board has observed the lack of supervision of medication queues throughout the year. How will the Governor ensure that staff are deployed to maintain adequate supervision?
Governor / Director
Belmarsh (2025)
Will the Governor continue to work with Practice Plus Group to improve the management and dispensing of medication within the prison?
Governor / Director
Foston Hall (2023)
The medication dispensing hatch remains unfit for purpose, with prisoners queuing outside in all weathers and not being assured of privacy if the queue isn’t well-managed. When will this be addressed?
Governor / Director
Drake Hall (2023)
More ways of controlling prescription medication need to be found to reduce the risks associated with trading medications.
Governor / Director
Five Wells (2025)
How are the new lockable lockers having an impact on the dispensing of medication?
Governor / Director
Five Wells (2025)
How are the new lockable lockers having an impact on the dispensing of medication?
Governor / Director
Featherstone (2020)
While the performance of healthcare staff appears adequate, there are a number of concerns: attendance at segregation reviews and use of force incidents; the monitoring of self-dispensing of medication held by prisoners; the operation of the healthcare complaints procedure; the thoroughness of mental health reviews and the reporting relationship with general healthcare. Can the Governor discuss these shortcomings with the …
Governor / Director
Feltham (2025)
Commission the Traka units for dispensing medication for use (Feltham B Governor).
Governor / Director
Bronzefield (2025)
What plans does the prison have to continue to improve co-ordination between the prison and NHS bodies in the timely dispensing of medications and the treatment of very unwell prisoners (6.1)?
Governor / Director
Class 1 Medicines Recall: Quetiapine Oral Suspension by Eaststone Limited - potential overdosing
Jan 2026 NatPSA/2026/002/MHRA
Contamination of non-sterile alcohol-free skin cleansing wipes with Burkholderia spp
Jun 2025 NatPSA/2025/002/UKHSA
Risk of oxytocin overdose during labour and childbirth
Sep 2024 NatPSA/2024/010/NHSPS
Inappropriate dosing risk when switching insulin degludec (Tresiba) products
Dec 2023 NatPSA/2023/016/DHSC
Contamination of carbomer-containing lubricating eye products with Burkholderia cenocepacia
Dec 2023 NatPSA/2023/015/UKHSA
Potential risk of underdosing with calcium gluconate in severe hyperkalaemia
Jun 2023 NatPSA/2023/007/MHRA
Steriflex Potassium Chloride, Sodium Chloride and Glucose IV fluid bags
Jan 2026 NatPSA/2026/001/DHSC
Supply of Licensed and Unlicensed Epidural Infusion Bags
Dec 2025 NatPSA/2025/007/DHSC
Shortage of bumetanide 1mg tablets
Jul 2025 NatPSA/2025/003/DHSC
Discontinuation of Promixin (colistimethate) powder for nebuliser solution
Mar 2025 NatPSA/2025/001/DHSC
Shortage of Pancreatic enzyme replacement therapy (PERT) - Additional actions
Dec 2024 NatPSA/2024/013/DHSC
Shortage of Molybdenum-99/Technetium-99m generators
Oct 2024 NatPSA/2024/012/DHSC
Discontinuation of Kay-Cee-L (potassium chloride) syrup
Oct 2024 NatPSA/2024/011/DHSC
Shortage of Human Albumin 4.5% and 5% dose vials
Jul 2024 NatPSA/2024/009/DHSC
Shortage of Kay-Cee-L (potassium chloride) syrup
Jul 2024 NatPSA/2024/008/DHSC
Shortage of Pancreatic enzyme replacement therapy (PERT)
May 2024 NatPSA/2024/007/DHSC
Shortage of Orencia ClickJect (abatacept) 125mg pre-filled pens
May 2024 NatPSA/2024/006/DHSC
Shortage of Erelzi (etanercept) 50mg pre-filled pen
May 2024 NatPSA/2024/005/DHSC
Shortage of salbutamol nebuliser liquid unit dose vials
Feb 2024 NatPSA/2024/003/DHSC
Shortage of GLP-1 receptor agonists (update)
Jan 2024 NatPSA/2024/001/DHSC
Shortage of verteporfin 15mg powder for solution for injection
Sep 2023 NatPSA/2023/012/DHSC
Shortage of ADHD medications (methylphenidate, lisdexamfetamine, guanfacine)
Sep 2023 NatPSA/2023/011/DHSC
Shortage of GLP-1 receptor agonists
Jul 2023 NatPSA/2023/008/DHSC
Shortage of pyridostigmine 60mg tablets
May 2023 NatPSA/2023/006/DHSC
Shortage of Antimicrobial Agents Used in Tuberculosis (TB) Treatment
Jul 2025 NatPSA/2025/004/DHSC
P-001392 — Royal Free London NHS Foundation Trust
Mrs E complains the Trust gave her late husband, Mr E, a stronger dose of chemotherapy medication than was required on 28 August 2019. She says the dose should have been reduced as he was experiencing an infection.
NHS in England Upheld May 2022
P-004438 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs O complains on behalf of herself and her husband, Mr O about Blackpool Teaching Hospitals NHS Foundation Trust (the Trust). Mrs O says on 24 April 2023 the Trust wrongly administered goserelin which was not intended for Mr O and it should have been given to another patient.
NHS in England Upheld Nov 2025
P-004653 — United Lincolnshire Teaching Hospitals NHS Trust
Mrs B complains about the care and treatment her father, Mr C, received by the Trust between April and May 2023. Specifically, she says the Trust did not give her father the correct medication, unsafely discharged him and delayed its complaint response because it lost his medical records.
NHS in England Partly Upheld Jan 2026
P-001072 — Manchester University NHS Foundation Trust
Ms A complains on behalf of her deceased brother, Mr B, who had a cardiac arrest at Manchester University NHS Foundation Trust, however the family were not made aware of this. Ms A also says that a doctor wrongly inserted an NG tube and instructed a nurse to inject 40mls …
NHS in England Upheld Jun 2021
P-001648 — University Hospitals of North Midlands NHS Trust
Mrs N complains the Trust did not apply her mother's fentanyl (a strong painkiller) patch properly. She says its record keeping was poor and she complains it skipped giving other medication. She says her mother was left without pain relief and then given morphine which was harmful to her.
NHS in England Oct 2022
P-001695 — The Dudley Group NHS Foundation Trust
Miss I complains about the Trust's care of her grandmother, Mrs E. Miss I complains the Trust wrongly gave Mrs E beta blockers, did not give her antibiotics for her foot at the right time, would not let family go to tests with her and that something went wrong during …
NHS in England Nov 2022
P-001620 — University Hospitals of North Midlands NHS Trust
Mrs A complains about her mother's, Mrs B's, end of life care saying the Trust did not give the right medication and antibiotics were delayed.
NHS in England Nov 2022
P-003849 — A practice in the Wigan area
Miss A complains the Practice issued several incorrect prescriptions to her which could have caused her to overdose.
NHS in England Sep 2023
P-002644 — A practice in the Bournemouth area
Ms F complained she received the wrong vaccine when she had her second dose of vaccination against COVID-19.
NHS in England May 2024
P-002693 — Imperial College Healthcare NHS Trust
Mr H complains that the London Trust inappropriately administered alteplase to his father although he was already taking blood-thinning medications. Mr H also complains that the Imperial Trust damaged an artery in his father’s brain when undertaking a procedure to remove the blood clot.
NHS in England Jun 2024
P-002876 — Warrington and Halton Hospitals NHS Foundation Trust
Mr P complains about the care he received at the Trust during an admission in November 2022. He complains staff gave him flucloxacillin despite him being allergic to it. He also complains about the nursing management of dressings for his skin condition.
NHS in England Partly Upheld Aug 2024
P-003175 — East Suffolk and North Essex NHS Foundation Trust
Miss R complains the Trust gave morphine to her mother in January 2024 despite her being allergic to it. She also complains that her mother was not prioritised in A&E and about the attitude of the nursing staff towards her care.
NHS in England Nov 2024
P-003199 — Hampshire Hospitals NHS Foundation Trust
Mrs O complains that in November 2022 her husband was given an overdose of Lidocaine at ten times the dose he should have been given.
NHS in England Dec 2024
P-003448 — East Sussex Healthcare NHS Trust
Miss B and her mother complain East Sussex Healthcare NHS Trust administered the wrong medication to Mr B just before he died, denied it gave him it and did not record this properly in the medication chart. They also complain it did not contact them soon enough when Mr B …
NHS in England Partly Upheld Mar 2025
P-003666 — Great Western Hospitals NHS Foundation Trust
Mr F complains about a lack of physiotherapy and poor nursing care his father received at the Trust. He also complains staff gave his father antibiotics he was allergic to.
NHS in England Jul 2025
P-004160 — Mid and South Essex NHS Foundation Trust
Mrs G complains during her husband’s admission in August and September 2023, the Trust administered a medication it should not have, failing to monitor its impact of his blood sugar, failing to provide appropriate nutrition considering his raised blood sugar, poor oral intake, weight loss and drowsiness. Mrs G also …
NHS in England Partly Upheld Oct 2025
P-004329 — United Lincolnshire Teaching Hospitals NHS Trust
Mrs D complains United Lincolnshire Teaching Hospitals NHS Trust (the Trust) prescribed her the wrong dose of breast cancer treatment drug between October 2024 and January 2025.
NHS in England Partly Upheld Nov 2025
P-004443 — The Royal Wolverhampton NHS Trust
Mr A complains the Trust gave his mother, Mrs A, penicillin from 15 May 2024 until her discharge from hospital on 27 May, despite her being allergic to this, and having chronic kidney disease.
NHS in England Dec 2025
P-004685 — A practice in the Chichester area
Mrs A complains about a GP Practice and a Pharmacy in the West Sussex area. She says the Pharmacy issued her daughter an incorrect prescription which led to an accidental staggered overdose, and the Practice refused to arrange an urgent appointment for her daughter at this time.
NHS in England Jan 2026
P-004606 — A practice in the Sandwell area
Miss L complains the Trust and Practice misdiagnosed her for seven months. She complains she was prescribed unnecessary medications due to the misdiagnosis.
NHS in England Upheld Jan 2026
P-004599 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Mr L complains about the combination of medication the Trust prescribed for his mental health and the side effects he suffered as a result.
NHS in England Jan 2026
P-001074 — Harrogate and District NHS Foundation Trust
Mrs A complains about aspects of the care and treatment staff at the Hospital gave to her father, stating that they were late giving her father his medication for Parkinson’s disease and did not give it at all several times, which increased her father’s confusion, caused him to hallucinate and …
NHS in England Partly Upheld Jun 2021
P-001084 — Pennine Acute Hospitals NHS Trust
Miss B complains about the Trust's decision to give her mother, Mrs A, morphine and midazolam shortly before she died. She believes these caused her mother to go into a comatosed state.
NHS in England Not Upheld Jul 2021
P-001184 — Wirral University Teaching Hospital NHS Foundation Trust
Miss R complains about the care and treatment Wirral University Teaching Hospital NHS Foundation Trust provided to her late father during an admission in October 2018. She complains the Trust did not treat sepsis with the correct antibiotics, gave him food and drink when nil by mouth and did not …
NHS in England Partly Upheld Nov 2021
P-001289 — The Dudley Group NHS Foundation Trust
Miss A complained about the care provided to her mother, Mrs E, at the Dudley Group NHS Foundation Trust. She says the Trust failed to appropriately test and treat her mother for chronic diarrhoea, and incorrectly administered Mrs E's medication.
NHS in England Partly Upheld Feb 2022
P-001385 — Lewisham and Greenwich NHS Trust
Ms E complains that Lewisham and Greenwich NHS Trust gave her incorrect treatment, documented incorrect information in her records relating to medication, and lost her ECG reports from 24 December 2018. She also says the Trust have failed to respond to her further letter of concerns.
NHS in England May 2022
P-001559 — West Hertfordshire Hospitals NHS Trust
Mrs A and Mrs Y complain the Trust wrongly stopped Mr Y’s antiplatelet medication and did not act on their concerns Mr Y was having a stroke. They also complain during the same admission the Trust delayed diagnosis of Mr Y’s peritoneal cancer.
NHS in England Partly Upheld Sep 2022
P-003901 — North Middlesex University Hospital NHS Trust
Mr A complains the Trust gave his mother three different medications in April 2021 and these caused her unexpected death.
NHS in England Jul 2023
P-002303 — South West Yorkshire Partnership NHS Foundation Trust
Miss H complains the Trust changed her olanzapine medication (an antipsychotic medicine used to treat schizophrenia) and would not let her go back on it.
NHS in England Upheld Nov 2023
P-002335 — East Kent Hospitals University NHS Foundation Trust
Mrs T complains the Trust incorrectly prescribed and gave glucose gel to her mother and it did not investigate when she was coughing and making gargling sounds.
NHS in England Dec 2023
P-002383 — Black Country Healthcare NHS Foundation Trust
Mr A complains the Trust wrongly prescribed his mother with antipsychotic medication.
NHS in England Dec 2023
P-002359 — University College London Hospitals NHS Foundation Trust
Mr A complains the Trust gave his wife 100mg of hydrocortisone during an inpatient stay in March 2022 and this led to her death.
NHS in England Dec 2023
P-002507 — Sheffield Teaching Hospitals NHS Foundation Trust
Miss E complains the Trust gave her mother an iron infusion too quickly.
NHS in England Mar 2024
P-002570 — Great Ormond Street Hospital for Children NHS Foundation …
Mr S complains the Trust gave his son an inappropriate dose of an immunoglobulin infusion, it did not understand his son's medical condition or give the right treatment and it did not give him oxygen properly.
NHS in England Apr 2024
P-002616 — South Tyneside and Sunderland NHS Foundation Trust
Mr A complains the Trust prescribed him a chemotherapy cream for longer than the recommended time and did not give any advice about it. Mrs A complains use of the cream have left him with permanent facial scarring.
NHS in England May 2024
P-002643 — Croydon Health Services NHS Trust
Mrs L complains the Trust failed to keep her husband in a private room, did not give him his diabetes medication, did not continue with antibiotics when his condition got worse and cancelled his discharge for no good reason.
NHS in England May 2024
P-002999 — Sherwood Forest Hospitals NHS Foundation Trust
Mrs E and Ms P complain the Trust wrongly stopped Mr W's edoxaban medication between 26 and 28 April 2023 and they it only gave him half a dose of thrombolysis medication instead of a full dose on 29 April 2023.
NHS in England Sep 2024
P-002909 — Mid Cheshire Hospitals NHS Foundation Trust
Mrs O complains about the Trust’s care and treatment of her father. She says it failed to refer him to the Speech and Language Therapy (SLT) team soon enough after his admission, it inappropriately changed her father’s fluid provision, it failed to treat her father as nil by mouth and …
NHS in England Upheld Sep 2024
P-003202 — Blackpool Teaching Hospitals NHS Foundation Trust
Mr R complains that the Blackpool Teaching Hospitals NHS Foundation Trust gave his mother incorrect doses of medication used for anaesthesia and procedural sedation from 11 August to 24 August 2021. He also complains the Trust did not discuss the Do Not Attempt Resuscitation Order decision before putting this in …
NHS in England Not Upheld Dec 2024
P-003542 — George Eliot Hospital NHS Trust
Mr and Mrs G complain that in October 2023, staff at the Trust prescribed incorrect antibiotic medication to their son after a pre-treated deep cut to his thigh becoming swollen. Mr and Mrs G also say the doctor told them it would be acceptable for their son to travel abroad …
NHS in England May 2025
P-003706 — Norfolk and Norwich University Hospitals NHS Foundation Trust
Mr L complains the Trust left him without eye drops for his cystinosis for eight weeks and failed to tell him when to stop taking his doxazosin medication whilst he was an inpatient.
NHS in England Jul 2025
P-003751 — East Kent Hospitals University NHS Foundation Trust
Mrs S complains about the timing of feeding tube insertion and reinsertion when it became dislodged. She also complains about the omission of prescribed anti-depressants.
NHS in England Aug 2025
P-003914 — Maidstone and Tunbridge Wells NHS Trust
Mrs U complains the Trust did not follow guidance when it gave intravenous (IV) fluids to her husband, Mr U, in November 2022.
NHS in England Sep 2025
P-004244 — Dartford and Gravesham NHS Trust
Mr D complains the Trust administered a medication to his mother that led to her death.
NHS in England Oct 2025
P-004162 — Wirral University Teaching Hospital NHS Foundation Trust
Mr A complains about the care and treatment the Trust provided to his wife in July/ August 2023. He says during his wife's hospital admission, the Trust gave her inappropriate antibiotics, left her on a trolley for an extended period of time and failed to provide appropriate nutritional care.
NHS in England Partly Upheld Oct 2025
P-004204 — University Hospitals Birmingham NHS Foundation Trust
Mr H complains about the care and treatment he received from the University Hospitals Birmingham NHS Foundation Trust in 2021. He complains the Trust gave him incorrect instructions on how to take his medication, delayed scans, incorrectly prescribed medication, provided a lack of mobility treatment and communicated poorly.
NHS in England Upheld Oct 2025
P-004453 — King's College Hospital NHS Foundation Trust
Miss P complains the Trust inappropriately prescribed medication to her father during an elective procedure.
NHS in England Dec 2025
P-004514 — A practice in the Gateshead area
Mrs G complains in April 2024, a medical practice in the Gateshead area did not reissue her medication at the previously agreed prescribed dosage, and its receptionist did not allow her to explain she felt suicidal or speak with the practice manager.
NHS in England Dec 2025
P-001063 — East Kent Hospitals University NHS Foundation Trust
Miss A complains East Kent Hospitals University NHS Foundation Trust (the Trust) did not provide her father adequate nutrition and hydration, his medication for Parkinson’s disease for five days, provide appropriately consideration for ‘Deprivation of Liberties’ (DOLS) when there was sufficient reason to do so or any physiotherapy during his …
NHS in England Upheld Apr 2021
P-001070 — The Dudley Group NHS Foundation Trust
Mrs M complains on behalf of her late father, Mr I. Mrs M complains that there was a delay in diagnosing Mr I’s stroke. Mrs M also complains that 6mg of morphine was administered to Mr I in one dose, which made subsequent assessment of his condition very difficult. Following …
NHS in England Partly Upheld May 2021
PSOW-202005941 — Cwm Taf Morgannwg University Health Board
Mrs A complained that a GP Practice in the area of Cwm Taf Morgannwg University Health Board failed to arrange a timely referral to secondary care for her late mother, Mrs G, between 20 January and 18 March 2020 in relation to increasingly painful symptoms in her lower left leg. …
PSOW (Public Services Om… Health Upheld Aug 2021
PSOW-202101243 — Cardiff and Vale University Health Board
Mr X complained that the Health Board had failed to prescribe him a newly approved medication called Fampridine, a drug used to improve walking ability in patients with multiple sclerosis. Mr X said this resulted in him paying for private prescriptions when he should have received the treatment from the …
PSOW (Public Services Om… Health Sep 2021
PSOW-202400150 — A GP Practice in the area of Cardiff …
Ms W complained that the Surgery had failed to respond to her complaint about her husband’s missing prescription. The Ombudsman decided that there had been a failure by the Surgery to respond to the complaint and this had caused frustration and uncertainty for Ms W. The Ombudsman decided to settle …
PSOW (Public Services Om… Health May 2024
NIPSO-202000068 — Belfast Health and Social Care Trust
We found the Belfast Trust was right to encourage a patient with cystic fibrosis to persevere with its chosen course of treatment, but criticised a lack of community dietetic support which left her at potential risk of harm.
NIPSO (NI Public Service… Health & Social Care Upheld Apr 2024
PSOW-202306591 — Aneurin Bevan University Health Board
Ms A complained about the care and treatment her mother received when in hospital. The Ombudsman found that the complaint response provided by the Health Board had not fully considered all aspects of Ms A’s concerns in line with relevant complaints guidance. Ms A had also indicated that she would …
PSOW (Public Services Om… Health Jan 2024
PSOW-202504068 — Swansea Bay University Health Board
Miss A complained that the Health Board prescribed and administered the incorrect dose of epilepsy medication to her 3-year old daughter when she attended the Emergency Department. Miss A said that despite having evidence of the prescribed medication, the Health Board said that there was no record of a prescription …
PSOW (Public Services Om… Health Oct 2025
PSOW-202201099 — Cardiff and Vale University Health Board
Mr X complained that the Health Board had failed to prescribe him a newly approved medication called Fampridine, a drug used to improve walking ability in patients with multiple sclerosis. Mr X said this resulted in him paying for private prescriptions when he should have received the treatment from the …
PSOW (Public Services Om… Health Jul 2022
21-003-612a — Livewell Southwest (21 003 612a)
Summary: Ms X complains about a lack of care and support provided to her late sister, Ms Y. Ms X says this enabled Ms Y to ingest items she should not have had access to, and that a serious incident report did not answer some of her questions about what …
LGO (Local Government & … Health Upheld Jun 2022
PSOW-202106456 — Cardiff and Vale University Health Board
Mrs X complained about the Health Board’s management of her chronic pain over the last year and about the unresolved issue of arranging a regular prescription of Lidocaine patches which has caused her pain and impacted on the quality of her life. Mrs X had complained to the Health Board …
PSOW (Public Services Om… Health Feb 2022
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