Poor medication withdrawal support
Absence of commissioned specialist services for GPs to help patients safely reduce or withdraw from prescribed dependency-forming medications.
50 items
6 sources
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
75match
Michael Barry
There is a critical lack of commissioned specialist services for GPs to safely manage patients reducing or withdrawing from prescribed dependency-forming medications, risking avoidable deaths.
Matched on
terms: medication
PFD report
73match
Paul Nash
A GP surgery failed to prioritise urgent seizure medication, and epilepsy patients nationally face difficulties obtaining sufficient quantities, leading to poor seizure control and potential delays.
Matched on
terms: medication, poor
PFD report
73match
James Day
Inadequate and difficult-to-access mental health support for service personnel with PTSD, both during and after service, forces individuals to self-medicate, leading to poor outcomes.
Matched on
terms: poor, support
PPO recommendation
73match
The Head of Healthcare
The Head of Healthcare should ensure there is a clinical process for monitoring prisoners who may be withdrawing from psychotropic medication associated with a risk of dependency and withdrawal.
Matched on
terms: medication, withdrawal
PFD report
69match
Aoife McAdam
A patient prescribed a cardiotoxic medication for anxiety was not advised to safely dispose of it after switching, leaving her with a significant, unneeded quantity that led to an overdose.
Matched on
terms: medication
PFD report
69match
Aaron Atkinson
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.
Matched on
terms: medication
PFD report
69match
Danielle Jones
The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the patient self-reporting multiple overdoses and external services raising concerns.
Matched on
terms: medication
PHSO casework decision
68match
P-003281 - The Dudley Group NHS Foundation Trust
Miss A complains about various decisions clinicians made during her mother’s admission in 2021.Findings leading to recommendationsWhat we are asking the Trust to do for Miss A:Complaint issueWhat we have seen so farWhat we are likely to ask the organisation to doWhat we would need to see and whenWithdrawal of medicationMs A’s steroid inhaler was withdrawn without taking...
Matched on
terms: medication, withdrawal
PFD report
65match
Pauline Meredith
Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's perceived reluctance to address family concerns. Delayed involvement of mental health services was also noted.
Matched on
terms: medication
PFD report
65match
Craig Hamilton
A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss alternative pain management, poses significant risks.
Matched on
terms: medication
PFD report
65match
Marcus Hamilton
The mental health service's rigid 28-day prescription policy for maintenance medication left a patient vulnerable during extended travel, providing unreliable advice about obtaining drugs illicitly abroad.
Matched on
terms: medication
PFD report
65match
Kathryn Barrow
GPs prescribed Diazepam without verifying consultant advice or checking for illicit access, and the practice had not reviewed its prescribing approach for this medication.
Matched on
terms: medication
PFD report
65match
Jacqueline Campbell
Dangerous polypharmacy involving escalating doses of synergistic pain medications led to central respiratory depression, exacerbated by difficulties for GPs in managing drug dependency and a lack of proactive medication review protocols.
Matched on
terms: medication
PFD report
65match
Amanda Kramer
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.
Matched on
terms: medication
PFD report
65match
Mark Smith
The GP practice lacked a system or policy to ensure appropriate medication reviews for vulnerable patients with addiction or self-harm history, risking stockpiling and misuse of prescribed drugs.
Matched on
terms: medication
PFD report
61match
John Ioannou
There is a lack of clear guidance for General Practitioners when patients fail to collect essential mental health medication, potentially compromising treatment continuity and patient well-being.
Matched on
terms: medication
PFD report
61match
Tania Hristova
The patient received antidepressant medication for over five years without adequate review and was not offered additional psychological therapies such as counselling or CBT.
Matched on
terms: medication
PFD report
61match
Scott Carton
Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without specialist input, compromises rehabilitation and increases re-offending risk.
Matched on
terms: support
PFD report
61match
Ruth Edwards
Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate history-taking led to underestimated risk, and insufficient GP medication reviews created an overdose risk.
Matched on
terms: medication
PFD report
61match
Michelle Jeffries
There is an absence of clear local guidance for GPs on safely prescribing multiple high-dose analgesics in the community and when a mandatory referral to a pain specialist is required.
Matched on
classifier match
PFD report
61match
Steven Bowker
The prolonged prescription and use of opiate medication pose significant dangers to patients.
Matched on
terms: medication
PFD report
61match
Sarah Keen
Critical patient information, including self-harm risk and medication details, was not communicated to carers. There was also a failure to standardize the understanding of medical abbreviations among staff, impacting patient safety.
Matched on
terms: medication
PFD report
61match
Jason White
Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of relapse and serious deterioration in the patient's mental health.
Matched on
terms: medication
PFD report
61match
Fallon Adams
There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative medications with illicit drugs, which can cause fatal over-sedation.
Matched on
terms: medication
Article 2 learning point
59match
Mr Everest — HMP Altcourse - LP 1
There needs to be much speedier medicines reconciliation, post reception. In prisoners, like Mr Everest, who are prescribed drugs like antidepressants, this needs to be within 24 hours to avoid withdrawal symptoms. There needs to be a robust administration process whereby a summary is acquired from the GP in the community, outlining the person’s medication. If someone is...
Matched on
terms: medication, withdrawal
PPO recommendation
56match
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.
Matched on
terms: medication
PFD report
53match
Thomas Pearson
A patient was prescribed fluticasone, increasing pneumonia risk without benefit due to a non-raised eosinophil count. The coroner recommends reviewing inhaled steroid use in similar patient populations.
Matched on
classifier match
PFD report
53match
Joy Ebanks
Prolonged prescribing of dependency-forming drugs (Oxycodone, Pregabalin) without reduction plans, despite internal guidance on the hazards of long-term use, contributed to toxicity.
Matched on
classifier match
PHSO casework decision
52match
P-001226 - A medical practice in the Hartlepool area
Mr R complains a medical practice in the Hartlepool area reduced and stopped his fentanyl medication too rapidly and without discussion.
Matched on
terms: medication
PHSO casework decision
52match
P-002804 - Torbay and South Devon NHS Foundation Trust
Mr E and Mrs O complain about the how the Trust managed their father’s withdrawal from alcohol during his admission.
Matched on
terms: withdrawal
PFD report
49match
John Michael Bailey
Date of report: 09/09/2013 Ref: 2013-0198 Deceased name: John Michael Bailey Coroners name: Jullian Fox Coroners Area: South Yorkshire (West) Category: Community health care and emergency services related deaths This report is being sent to: Department of Health and Social Care
Matched on
classifier match
PFD report
49match
Carly Gordon
The long-term use of shorter-acting benzodiazepines, contrary to guidelines, and a failure to review patients on extended prescriptions risked dependence and adverse outcomes.
Matched on
classifier match
PFD report
49match
KennethDaly
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.
Matched on
classifier match
PFD report
49match
Robert Stevenson
Prescribing doctors may be unaware of a rare potential link between Ciprofloxacin/Quinolone antibiotics and suicidal behaviour, especially in depressed patients. Guidelines should be reviewed to increase awareness and mitigate this risk.
Matched on
classifier match
PFD report
49match
Louise Rosendale
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.
Matched on
classifier match
PHSO casework decision
48match
P-002761 - A practice in the Hackney area
Miss P complains about how the Practice cared for her mother. She says it stopped medication rather than reduce it slowly and it failed to review her mother after a month. She also says it lied in its complaint response.
Matched on
terms: medication
IMB recommendation
47match
Cardiff (2023)
Given the frequent applications received by the Board regarding prescription medication, can consideration be given to how the impact of a change to, or ending of, prisoners’ usual medication can be minimised, and prisoners better supported and informed through this?
Matched on
terms: medication, support
PFD report
45match
Lee Bonsall
Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it an unviable treatment alternative.
Matched on
classifier match
PFD report
45match
Deanne Smith
The practice of dispensing large quantities of methadone to drug-dependent individuals over public holidays increases the risk of future deaths and needs policy review.
Matched on
classifier match
PFD report
45match
Lakhminder Kaur
Concerns arose regarding unmanaged long-term zopiclone addiction and the immediate cessation of the drug, which was done to prevent serious self-harm.
Matched on
classifier match
PHSO casework decision
44match
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.
Matched on
terms: medication
PHSO casework decision
44match
P-002748 - Surrey and Sussex Healthcare NHS Trust
Mrs L complains the Trust incorrectly stopped medication to treat her mental health condition which led to a long hospital stay and affected her mobility and mental health.
Matched on
terms: medication
PPO recommendation
43match
The Head of Healthcare at HMP Thameside
The Head of Healthcare at HMP Thameside should ensure that prisoners are discharged or transferred with a sufficient supply of their prescribed medications.
Matched on
terms: medication
Scottish FAI
43match
Scott Andrew Ross
Co-ordinated approach between hospital and prison for drug withdrawal management; proper dosage for benzodiazepine discontinuation; NHS Tayside to review drug withdrawal protocols; timely passage of clinical information between prison and hospital
Matched on
terms: withdrawal
PHSO casework decision
39match
P-003121 - Cheshire and Wirral Partnership NHS Foundation Trust
Mr R complains the Trust decided to stop his clozapine medication after a standard monthly blood test on 18 July 2023, without putting in place an alternative treatment plan.
Matched on
terms: medication
PHSO casework decision
39match
P-004419 - Greater Manchester Mental Health NHS Foundation Trust
Mrs A complains about the discharge process and the lack of medication reviews prior to discharge.
Matched on
terms: medication
Article 2 learning point
35match
Mr Everest — HMP Altcourse - LP 2
If a prisoner comes into prison on mirtazapine, he/she should have a full review, following confirmation of that prescription from the community GP. This should happen quickly. If an alternative to mirtazapine prescription is appropriate, the person should be reduced slowly from mirtazapine and the new drug introduced gradually, as per the Maudsley Prescribing Guidelines. If mirtazapine prescription...
Matched on
classifier match
PPO recommendation
32match
The Head of Healthcare (HMP Nottingham)
The Head of Healthcare should work in partnership with Nottingham Healthcare NHS Foundation Trust, the regional Health and Justice Leads and regional drug providers to satisfy themselves that the local policy on the offer and issue of naloxone on release captures prison leavers with previous opiate use and other relevant risk factors, not just those on the substance...
Matched on
classifier match
PPO recommendation
27match
The Head of Service Delivery for substance misuse
The Head of Service Delivery for substance misuse should satisfy themselves that the local policy on the offer and issue of naloxone on release captures prison leavers with previous opiate use and other relevant risk factors.
Matched on
classifier match