Poor medicines audit response
Failure to promptly respond to findings from medicines audits and seek current guidance on medication management.
76 items
6 sources
Source spread
Where this theme appears
Poor medicines audit response has been flagged across 6 independent accountability sources:
55 PFD reports
3 committee recs
11 CQC actions
4 PPO recs
1 Scottish FAI
2 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.
PFD Reports (55) — showing 50 strongest matches
Judith Marshall
Concerns: The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory read-back procedures, and a central error database.
Response (General Pharmaceutical Council): The General Pharmaceutical Council acknowledges the concerns and states they are considering publishing an anonymised summary of the case in their newsletter 'Regulate'. It highlights existing guidance and standards, including …
Response (NHS England): NHS England describes actions underway to improve medication safety, including publishing a new Patient Safety Alert on medication errors in March 2014. It also mentions a review of community pharmacy …
Response (Royal Pharmaceutical Society): The Royal Pharmaceutical Society acknowledges the concerns and says it could raise awareness and encourage use of 'read-back' as one technique amongst others to reduce errors in the guidance that …
Response (Department of Health): The Department of Health describes actions taken to address concerns around dispensing errors, including the MHRA working with NHS England to simplify medication error reporting. An integrated reporting route has …
Responded
Lee Curran
Concerns: PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored by doctors. Additionally, prison staff lacked training in accurate medical note-taking, leading to incorrect entries.
Overdue
Peter Brookes
Concerns: Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and an unresolved dispensing error causing wrong medication.
Response (University College London Hospitals NHS Foundation Trust): The Trust has a policy that all new patients should have their medication reconciliation completed within 24 hours and are looking to achieve 100% compliance. It also has measures in …
Responded
Mr Pether
Concerns: Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options despite deteriorating clinical condition.
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
Paul Hardy
Concerns: Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct a Significant Event Analysis.
Overdue
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
Kathleen Neville
Concerns: The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future deaths, particularly in other Health Boards without such a policy.
Overdue
Maureen Chatterley
Concerns: Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification of medication quantities and increasing risk of misuse or error.
Response (Bolton NHS Trust): Bolton NHS Trust will introduce a new Wardex for pharmacists to record reviews and develop a local endorsement policy by February 2016. Safe and Secure Handling of Medicines Audits (Duthie) …
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
Benjamin Brown
Concerns: Concerns identified inadequate auditing of 15-minute observations and clozapine management, alongside insufficient staff training for patient resuscitation.
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
Kay Morrison
Concerns: There is an insufficient system for collating appropriate antibiotic history, potentially across many hospitals, and a lack of clear requirements for Trusts to adhere to national guidelines on this crucial patient information.
Overdue
Daphne Penn
Concerns: Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose reduction without sufficient clinical oversight.
Overdue
Kathleen Bamforth
Concerns: Concerns exist regarding current practice guidelines for clomipramine prescription, specifically the merits of routine blood screens for patients on long-term use.
Response (Department of Health): The Department of Health acknowledges the concerns and provides information on NICE guidelines and SmPC recommendations for clomipramine and tramadol. The MHRA is seeking advice from experts on routine blood …
Responded
Cuthbert Hingert
Concerns: Significant medication errors, including duplicate prescribing and incorrect dosages, occurred due to clinicians failing to check databases and insufficient training. A nurse also failed to report these errors according to protocol.
Overdue
Joan Wright
Concerns: Issues included inconsistent opioid handling, unaddressed statutory oversight for drug responsibilities, police failure to recognise safeguarding risks in medication errors, and a lack of statutory definition for "regular" medication checks in care homes.
Response (Department of Health): The Department of Health outlines existing regulations and guidance regarding controlled drugs, referencing the Shipman Inquiry, the Controlled Drugs Regulations 2006, NICE guidelines and CQC guidance; the Department suggests taking …
Responded
Thomas Jackson
Concerns: Poor record-keeping, inadequate preparation and attendance at multidisciplinary meetings, and staff unfamiliarity with Clozapine's significance hindered patient care. Inaccuracies in serious incident reviews also compromised learning.
Response (Department of Health and Social Care): • Officials have made enquiries with a number of bodies regarding routine therapeutic blood monitoring for patients prescribed clozapine. • The NICE guideline CG178, which supports routine monitoring of physical …
Overdue
Malcolm Rathmell
Concerns: Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based pharmacy review, with proposed actions still in infancy.
Response (North East London NHS Foundation Trust): North East London NHS Foundation Trust will provide record keeping training to staff, develop and implement a discharge checklist, conduct audits, update the HTT Service Operational procedure, and update the …
Response (Department of Health and Social Care): The Department of Health and Social Care expresses sympathy and states that they expect the North East London NHS Foundation Trust to look carefully at the care provided and take …
Responded
Feni Lee
Concerns: An inadequate medication review failed to address unlicensed drug use and a vulnerable patient's needs, compounded by severe delays in internal post redirection between GP practices for critical hospital correspondence.
Response (Bexley Medical Group): The practice has started implementing a plan to carry out medication reviews in all patients who have not had a review for over 12 months. The practice has discussed the …
Overdue
Michael Lobban
Concerns: Boots' controlled drug audit and investigation processes for methadone disparities were inadequate, and the General Pharmaceutical Council lacks sufficient reporting requirements, investigative powers, and sanctions for such discrepancies.
Overdue
Sandra Scott
Concerns: A GP system flaw prevented a patient from receiving prescribed medication, and hospital staff failed to act on critical test results for a discharged patient, both contributing to preventable death.
Overdue
Elaine Renshaw
Concerns: Inadequate controlled drug check processes in care homes resulted in unaccounted drugs and inaccurate stock sheets, highlighting a national lack of clear guidelines for controlled drug handling and recording.
Overdue
Peter Cole
Concerns: Inadequate monitoring of repeat medication allows vulnerable patients to accumulate dangerous quantities, a widespread problem leading to significant waste of healthcare resources.
Response (NHS England): NHS England references the Long Term Plan as covering monitoring of repeat prescribing. It also highlights the Medicines Safety Improvement Programme and the Dementia Care Pathway guidance, both of which …
Responded
Mildred Horrex
Concerns: Poor record-keeping, including insufficient and inaccurate admission information, led to an inadequate fall risk assessment. Additionally, monthly drug audits failed to identify critical discrepancies between medication charts and actual stock.
Response (Pelham House): Pelham House has implemented several changes including family members signing pre-assessment forms, recording calls, implementing a new CQC-recognized care plan system, employing an external auditor for monthly audits, and ensuring …
Responded
Theresa Robertson
Concerns: The surgery failed to document critical patient calls and consultations. A doctor prescribed medication for a high-risk patient outside policy, with no audit to identify similar systemic breaches in prescription safety.
Overdue
Ian Allen
Concerns: The Trust failed to act on high clozapine levels due to poor monitoring systems and a lack of understanding regarding its importance. National guidance is needed for monitoring frequency and practitioner education on clozapine.
Response (Birmingham and Solihull Mental Health Trust): Birmingham and Solihull Mental Health Trust has provided pharmacists with additional training on Clozapine, will build further education into the Post Graduate Medical Education programme and is drafting a safety …
Response (Dept Health and Social Care): The Department of Health and Social Care notes that Birmingham and Solihull Mental Health NHS Foundation Trust has responded to the report by undertaking a review and update of its …
Responded
Katie Corrigan
Concerns: There is no national system for circulating patient alerts to pharmacies or GPs regarding inappropriate opiate prescriptions. This allowed the deceased to improperly obtain lethal quantities of medication.
Response (CQC): CQC has inspected registered online providers identified from the inquest and taken regulatory action where needed. They are investigating unregistered providers and are exploring ways to strengthen regulation of online …
Response (Dept of Health and Social Care): The Department of Health and Social Care is working with healthcare and professional regulators to strengthen the regulation of independent online prescribers. NHS England and Improvement are implementing recommendations from …
Responded
Rhian Roberts
Concerns: A toxicology screen requested on arrival at ICU may not have been undertaken; an updated SOP for communicating life-threatening blood results was still in draft form; and there are concerns about continual delays in investigating adverse incidents, sharing learning and implementing actions.
Overdue
Kumbulani Mtombeni
Concerns: Methadone prescribed to a care home resident was found in a staff member's possession, raising serious concerns about medication management, security, and auditing protocols.
Response (Care Outlook): Care Outlook has implemented a digital care planning and monitoring system, will ensure all medication auditors and managers understand their obligation and have introduced a training program.
Responded
Mohammed Salam
Concerns: The Root Cause Analysis for a medication omission lacked rigor, failing to investigate causal factors or consequences, which raises concerns about organizational governance and learning from deaths.
Response (Northern Care Alliance NHS Foundation Trust): Northern Care Alliance has implemented consultant countersignatures on ward round outcomes, updated grand round and weekend handover proformas to include an ePMA review checkbox, and updated the junior doctors' handbook …
Responded
Margaret Toye
Concerns: Failure to assess malnutrition risk using the MUST score and erroneous documentation meant necessary nutritional interventions were not implemented, despite known widespread non-compliance on the ward.
Overdue
Alan Hodgson
Concerns: Failures in opiate administration, senior doctor review, adherence to established pathways, inter-departmental communication, and continuity of care were compounded by an insufficient internal review process.
Overdue
Trevor Reynolds
Concerns: The health board experienced significant delays in fully implementing a new Standard Operating Procedure for irregular scan reports and auditing its effectiveness, allowing known patient risks to continue.
Response (Betsi Cadwaladr University Health Board): The Health Board has made all oncology and haematology staff aware of the SOP for escalating urgent radiology results and added it to the induction checklist and secretarial meetings. Audits …
Overdue
Karen Redding
Concerns: Care staff failed to check medication contents upon request and did not ensure a doctor's review after the resident disclosed an overdose, despite her declining help.
Response (Cherish Home Care Ltd): Cherish Home Care now conducts spot checks with carers every 3 months (increased from annually) which will cover medication. During double up calls, carers are required to work together when …
Responded
Seema Haribhai
Concerns: The report identifies that an Ayurvedic practitioner did not recognise that the cause of a patient's yellow discolouration might be her own prescription, and GPs did not record details of patient history or advise immediate cessation of Ayurvedic medicines.
Response (Ayurvedic Professionals Association): The APA will write to the Indian High Commission to suggest a review of Indian herbal imports and will petition the Food Standards Agency to require herb labelling to display …
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA explains its Yellow Card scheme for reporting adverse drug reactions, clarifies why a report couldn't be submitted in this case due to lack of product details, and notes …
Overdue
Beryl Ellison
Concerns: Inadequate supervision of syringe medication and unchanged care home systems, despite prior family concerns, contributed to a resident's fatal overdose of oxycodone.
Response (Four Seasons Health Care Group): Four Seasons Health Care Group has implemented improved communication, incident escalation, and medication risk assessment processes to prevent future medication errors. These include notifying management of incidents promptly, regular clinical …
Responded
John Abrahams
Concerns: Recommendations from the Isotretinoin Expert Working Group for prescribing to under-18s have not been implemented over a year later, despite ongoing adverse psychiatric events, including attempted suicide.
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA convened the Isotretinoin Expert Working Group (IEWG) to evaluate data on risks associated with isotretinoin and the Implementation Working Group has had two meetings in March 2023 and …
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA published a report on isotretinoin's side effects and issued a Drug Safety Update. An Implementation Working Group is developing recommendations for safe introduction of new measures, with outputs …
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges concerns regarding Isotretinoin and refers to the MHRA's response; they note that the Isotretinoin Implementation Working Group has met and is drafting …
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
Hazel Pearson
Concerns: Inadequate management of food intolerances and allergies, including slow implementation of safety measures and a lack of proper incident investigation and Datix reporting, poses a serious risk.
Response (Betsi Cadwaladr University Health Board): The Health Board is exploring how to access expert advice in relation to compliance. A revised training programme for incident reporting is in place for all staff with dates confirmed …
Responded
Glenn Lockwood
Concerns: Insufficient monitoring for Pregabalin abuse in a patient with a known drug abuse history was identified, and the review of record-keeping and prescribing issues for the drug was found to be inadequate.
Response (ClydeCo): The response provides a summary of the inquest findings, including the deceased's medical history and the coroner's conclusion of a drug-related death. It notes that a report will be issued …
Response (The Limehouse Practice): The Limehouse Practice will conduct SEA training for prescribers, review prescribing for patients at risk of dependence, document medication changes, and provide refresher training on EMIS prescribing function. They have …
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
Norman Leadbeater
Concerns: Inadequate care plans and missing medication details on the Medication Administration Record (MAR) led to unsafe fluid administration. A critical audit and liaison with GPs remain incomplete months after recommendation.
Response (Evolve): The company has audited MAR sheets for all service users. The Staff Induction has been revisited and greatly improved, with additional training and more observations of staff during their shift, …
Responded
Debra Bates
Concerns: A recommendation for restricted medication dispensing to manage chaotic pill use was rejected due to perceived logistical issues, without adequately exploring implementation strategies or system safeguards.
Response (Park Surgery Heanor): The surgery plans to discuss the SOP during an education session, undertake quality improvement work on opioid prescribing (including patient reviews), and review the SOP in July 2025.
Responded
David Morris
Concerns: Delays in cancer diagnosis and treatment were caused by poor organisation and communication. Staff failed to identify and escalate sepsis, clinical records were poor, and controlled drug management systems were ineffective.
Response (Barking Havering and Redbridge NHS Trust): The Trust will not allow removal or deferral of cancer patients on a Patient Tracker List without consultant approval. A restructure of cancer administration pathways is underway and an external …
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA acknowledges the concerns but states they cannot comment on medical advice or care quality. They explain the MHRA's role in assessing medical devices and note they received a …
Response (Department of Health and Social Care): The DHSC acknowledges the concerns regarding the care provided by the Trust and its processes. It outlines the roles of NHS England, CQC and MHRA and refers to NICE guidance …
Responded
Shahida Khan
Concerns: A patient received toxic and fatal quantities of medication from care home staff through an unknown mechanism, highlighting an unexplained risk of recurring, lethal medication errors.
Response (Voyage Care): Voyage Care describes actions taken including reviewing resident care plans, medication training for staff, and commissioning an independent pharmacist to review policies. They are also planning the implementation of an …
Responded
Gemma Ralph
Concerns: Inadequate monitoring and auditing of Sevoflurane stock allowed a bottle to be removed from the hospital unflagged. The trust could not confirm if the drug found originated from their facility.
Response (NHS England): NHS England acknowledges concerns about the monitoring of Sevoflurane and refers to professional guidance from the Royal Pharmaceutical Society and CQC regulations. They note the hospital's response and mention internal …
Response (Wolverhampton NHS): The trust has reduced the amount of sevoflurane stored in each theatre and implemented locked drug cupboards. They are also submitting a business case to purchase and install automated medicines …
Responded
Teresa Auriemma
Concerns: Doctors repeatedly failed to follow policy for hypokalaemia, resulting in inadequate daily monitoring of potassium levels and inappropriate administration of intravenous potassium, despite prior inquests highlighting similar electrolyte monitoring failures.
Response (Worcestershire Acute Hospitals NHS Trust): Worcestershire Acute Hospitals NHS Trust sent an advisory notice to doctors reminding them to prescribe IV fluids and monitor electrolytes as per NICE guidance, set up a working party to …
Responded
David Crompton
Concerns: The pharmacy repeatedly failed to promptly supply essential anti-epileptic medication, leaving the patient without treatment and lacking clear systems for managing supply shortages.
Response (Midway Pharmacy): Midway Pharmacy has reviewed SOPs to promptly identify owings, engages colleagues to ensure adherence, and sources medication from other pharmacies/wholesalers when possible. From March 3, 2025, patients with owings will …
Response (General Pharmaceutical Council): The GPhC has opened an investigation into the concerns raised in the regulation 28 report. A GPhC inspection found the pharmacy had robust processes to manage out-of-stock medicines, including electronic …
Responded
Christopher Bradbury
Concerns: A national lack of knowledge and guidelines for Severe Invasive Soft Tissue Infections, combined with ineffective training and an absence of an audit trail for omitted medication doses, creates significant patient safety risks.
Response (NHS England): NHS England will ensure emphasis on escalation of deteriorating patients with skin and soft-tissue infections during a revisit of statutory and mandatory training for infection and prevention control this year.
Response (University Hospitals of North Midlands NHS Trust): The Trust is implementing an Electronic Prescribing and Medicines Administration (EPMA) system across both sites, which will provide a record of medication activity. In the interim, a Patient Safety Learning …
Responded
Committee Recommendations (3)
#5 — Review the effectiveness of Serious Shortage Protocols, focusing on timing and administrative burden.
Recommendation: We recommend that the Government reviews the effectiveness of Serious Shortage Protocols, with a focus on their timing and their administrative burden. (Paragraph 49) 44 Pharmacy
Gov response: National Patient Safety Alerts (NPSAs) apply to all prescribers. The government expects providers of healthcare services and those with responsibility for prescribing to take appropriate account of national guidance. Professional regulators have issued joint statements …
Accepted
#4 — Medicine shortages risk negating general practice capacity gains from Pharmacy First.
Recommendation: It is also especially worrying that shortages are resulting in patients being directed back into general practice. There is a serious risk that any capacity that general practice gains, through services like Pharmacy First, will be negated by the time …
Gov response: As above, the Human Medicines Regulations 2012 (HMRs 2012) require pharmacists to dispense “in accordance with a prescription”. This has been interpreted to mean supply of medicines must be the exact product and quantity prescribed …
Accepted
#3 — Medicine shortages undermine community pharmacy potential and erode public confidence.
Recommendation: Tackling medicine shortages is another vital component in securing the ability of pharmacy to meet its future potential. Medicine shortages cannot be ignored and left to become the norm. The wider implications of medicine shortages for the long- term potential …
Gov response: The Human Medicines Regulations 2012 (HMRs 2012) require pharmacists to dispense “in accordance with a prescription”. This has been interpreted to mean supply of medicines must be the exact product and quantity prescribed with some …
Partially Accepted
CQC Inspection Actions (11)
Colney Lodge Limited
The provider must ensure medicine audits are in place. Medicine administration records (MAR) must be completed accurately and not signed ahead of time. Risk assessments must be in place for managing refusal of medication.
Must Do
Tralee Rest Home
Medication audits had failed to identify that equipment used to check blood sugar levels was not calibrated, or that there was no stock of calibration fluid held within the service.
Should Do
Sydenham House
Establish a programme of medicines auditsto ensure staff are practicing in line with current guidance.
Should Do
Oak Tree Manor
There were medication audits but like the other audits they did not pick up on the areas identified at the inspection.
Should Do
Medrescue Headquarters
Theserviceshouldensureithaseffectiveoversightforthelicensingofcontrolleddrugsandthatapplicationsto renewaremadeinatimelymanner.
Should Do
Head Office
We recommend that the provider reviews their medicine administration auditing processes to ensure safe administration of medicines at all times.
Should Do
Applegarth Care Home
The service to seek current guidance on how to respond promptly to findings from medicines audit.
Should Do
Tralee Rest Home
Audits of procedures, such as recruitment, had failed to identify missing steps when convictions were recorded and, additionally, had failed to identify gaps within policies to deal with this.
Should Do
Medrescue Headquarters
Theprovidershouldconsidertheprocessusedtoreceiveandactonmedicinesalerts.
Should Do
Gillmoss Medical Centre
Ensuremedicinessafetyalertsareactedonwithoutdelay.
Should Do
Unit 4 Cornishway Industrial Estate
Operate a stock control system to monitor single use items and ensure that they remain in date
Should Do
PPO Death in Custody Recommendations (4)
The Head of Healthcare
The Head of Healthcare should ensure that the new measures in place are audited at frequent intervals to ensure that pain relief and end of life medications are sourced and dispensed in a timely manner.
The Chief Executive of NHS Wales
The Chief Executive of NHS Wales should investigate whether Parc followed the PGD regulations and whether the use of verbal instructions by GPs for nurses to dispense prescription-only medicines from the out-of-hours medication cupboard complies with regulations.
The Head of Healthcare
The Head of Healthcare should investigate why Mr Walton’s abnormal blood and urine tests were not reviewed by a doctor and put systems in place to ensure that this does not happen in the future.
The Head of Healthcare
The Head of Healthcare should review the systems for medicines management to identify systemic issues with prescribing.
Scottish Fatal Accident Inquiries (1)
PHSO Casework Decisions (2)
P-002576 — A practice in the Rutland area
Miss A complains the Practice failed to refer her to Adult Autism Services for 13 months and it did not include the correct information on the referral. She also says the Practice did not review her medication.
NHS in England
Apr 2024
P-002567 — A practice in the Suffolk area
Mrs A complains about how the Practice reviewed her medication in May 2022.
NHS in England
Apr 2024