Unsafe medication management
119 items
2 sources
Failures in the safe management of medicines, including storage, administration, record-keeping, prescribing, and disposal.
Cross-Source Insight
Unsafe medication management has been flagged across 2 independent accountability sources:
1 inquiry rec
118 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
PFD Reports (118) — showing 100 most recent
Valerie Gibson
Concerns: Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks of over/under medication and patient harm.
Response: The Trust has completed comprehensive training for all nursing staff and amended its Medicine’s Management Policy to ensure medication is dispensed before administration. They have also updated e-learning packages and …
Responded
Paula Doreen
Concerns: National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent management of therapeutic excess persists, and new systems risk losing safety nets.
Response: NHS England explains that the Cerner system's duplicate checking functionality was available but likely not enabled and defers to the Royal College of Physicians for national ACVPU assessment training. NHS …
Response: The MHRA outlines existing Human Medicines Regulations 2012 regarding the labelling and warnings for paracetamol medicines and its role in monitoring medicine safety. The MHRA has liaised with NHS England, …
Response: The Royal Pharmaceutical Society (RPS) notes the concerns, clarifying its non-regulatory role and stating that most electronic prescribing systems have duplication alerts, though these often require national oversight to improve. …
Response: Lewisham and Greenwich NHS Trust's electronic prescribing system includes 'hard stop' alerts for concurrent paracetamol prescriptions and dose range checking, with oral dose range checking slated for an update. The …
Response: Oracle Health disputes any defect or fault in its Millennium software regarding concurrent paracetamol prescriptions, stating the functionality exists but is an optional, client-configurable setting. Oracle Health affirms its system …
Responded
Thompson Elliott
Concerns: Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in an opioid overdose and continued use of harmful medication.
Response: Care UK has conducted extensive staff discussions and reminded all care homes of internal policies on discharge information and handover procedures. The Grangewood care home has updated its contact document …
Responded
Robert Simpson
Concerns: A patient was discharged with incorrect medication and missed critical antibiotic doses due to stock issues and poor communication, highlighting systemic failures in medication management and escalation.
Responded
Sheldon Jeans
Concerns: The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications creates significant safety risks within the prison estate.
Responded
Peter McCarthy
Concerns: Care staff lacked protocols to prevent administering anticoagulant medication to clients who had fallen, due to an inability to identify contraindications without medical oversight.
Overdue
Oliver Billings
Concerns: A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented error detection. The patient was inappropriately burdened with resolving the pharmacy's error.
Responded
Amanda Richardson
Concerns: Systemic failures in medication review led to a patient receiving double the maximum dose for six months. Additionally, inadequate security and search procedures in a mental health hospital allowed illicit drugs to be present.
Overdue
Anthony Nixon
Concerns: A pharmacist unilaterally provided multiple advanced doses of a controlled drug, contrary to supervised prescription instructions and without informing the treatment provider, significantly increasing overdose risk.
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.
Responded
Sewa Chaddha
Concerns: Pharmacists lacked guidance for dispensing medication to cognitively impaired patients, leading to identical dosset boxes for cohabiting individuals, which directly contributed to medication mix-ups and posed a safety risk.
Responded
Antony Waring
Concerns: A highly inappropriate surgical technique for suprapubic catheter insertion in a complex patient led to bowel perforation, compounded by inadequate use of imaging guidance and specialist consultation despite known risks.
Responded
Lee Hughes
Concerns: There was a serious failure to manage the deceased's intoxication and unrousable state in prison, with medical help not sought despite clear signs. Critical opportunities for escalation and appropriate care were missed.
Responded
Kim Stroud
Concerns: There was non-compliance with medication administration, with tablets left unsupervised for a patient with delirium, and serious failures in personal care.
Responded
Georgia Dehaney-Perkins
Concerns: A patient with a self-harm history was placed in a room with a faulty anti-ligature mechanism without risk assessment, and medication risks with alcohol were not communicated. Inconsistent recording of alcohol consumption and ignored family concerns compromised patient safety.
Responded
Charlene Roberts
Concerns: Systemic failures in managing a complex patient included unquestioned long-term cyclizine prescribing, inadequate supervision, and a lack of specialist dual-diagnosis treatment options, allowing the patient to self-harm.
Responded
Steven Sanders
Concerns: An endemic problem of illicit drug use and supply within the secure mental health hospital, inadequately mitigated, poses significant risk to vulnerable patients with mental illness and compromised judgment.
Overdue
Alison Ross
Concerns: There is no clear guidance for monitoring patients who self-administer medications but do not take them at the time of dispensing, posing a risk to medication adherence.
Responded
Anthony Rockall
Concerns: Unsafe unloading practices using an incompatible pallet truck and heavy loads on tailgates persist without review, despite previous warnings, creating a significant risk of falls and fatal injuries.
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.
Overdue
Gavin Pedleham
Concerns: There is a lack of regulation governing the safe storage and access of controlled drugs like Oramorph in community settings, unlike highly regulated institutional environments.
Responded
Tracy Brown
Concerns: Carers regularly left medication unsecured, despite an identified risk of misuse. The digital care plan also failed to instruct carers to secure the medication, posing a safety risk.
Responded
Susan Perry
Concerns: Medication cupboard keys were left in easily accessible, unlocked locations nearby, compromising medication security and creating a significant risk of service users accessing and misusing drugs.
Responded
Janice Hopper
Concerns: The care plan was inaccurate, not person-specific, and vital medical monitoring—including weight, blood sugar, and fluid intake—was neglected or poorly recorded. Additionally, medication was administered inappropriately and care plans lacked regular review or audit.
Responded
Lewis Begley
Concerns: The mental health hospital lacked a proper record of stored medication, especially drugs subject to misuse, and had no system to track patient access or provide fixed overdose treatment training for doctors.
Responded
Cristofaro Priolo
Concerns: Improper food preparation, unassessed feeding techniques, and inadequate staff training in choking first aid and CPR led to unsafe feeding practices and a failure to recognise and respond to cardiac arrest.
Responded
Tracy Wood
Concerns: Insufficient staffing, failure of a duty doctor to assess a patient, unapproved medication administration without proper tracking, and significant inaccuracies in clinical records led to compromised care.
Responded
Mark Athias
Concerns: The nursing home lacked essential sterile catheter supplies, leading to a patient's emergency hospital admission and subsequent deterioration.
Responded
Idris Habib
Concerns: Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect also existed between prison policy and officers' actions.
Responded
Ian Miller
Concerns: A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading of prescribed medication, posing a significant risk to prisoner safety.
Overdue
Maria McGauran
Concerns: The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about the patient's excessive use and hoarding of codeine.
Responded
Saif Hussain
Concerns: The trust lacked a single, integrated system for drug record-keeping and monitoring, with insufficient limits on administration and inadequate implementation of safety software like Guardrails.
Responded
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.
Responded
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.
Responded
Ian Hall
Concerns: Incorrect medication was dispensed, and pharmacies lack checks to prevent vulnerable adults, whose non-clinical carers administer medications, from receiving wrong prescriptions.
Overdue
Helen Spicer
Concerns: Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without accountability.
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.
Responded
Rohan Singh
Concerns: A mental health ward failed to prevent a patient from retaining dangerous contraband despite searches. Staff made false observation records due to a culture of impunity, and critical monitoring protocols after rapid tranquilisation were not followed.
Responded
Yusuf Seyit
Concerns: A high-risk patient with infection symptoms did not receive timely antibiotic intervention. There was no clear treatment plan, and the actual administration time for a critical antibiotic was not confirmed.
Responded
Michael Dent-Jones
Concerns: National Probation Service Approved Premises staff and management were unaware of and not implementing policies for managing residents' prescribed medication. Procedures were absent, and staff had not read essential safety documents, indicating broader safety failures.
Responded
Geoffrey Banks
Concerns: A vulnerable patient's medication was unsafely stored due to a faulty lock, despite being identified as needing supervision, compounded by a poor investigation by untrained staff.
Responded
Neville Bardoliwalla
Concerns: A lack of a process for collecting and disposing of prescribed controlled medication allowed for its accumulation, posing a significant risk.
Responded
Leslie Clewarth
Concerns: Inadequate record-keeping of care provided and medication dosage made it impossible to corroborate staff actions and risked erroneous or duplicated patient care.
Responded
Marian Day
Concerns: Anticoagulant prescription errors remain unexplained, indicating a risk of recurrence due to muddled documentation, lack of senior review, and absence of a clear prescription plan for staff.
Responded
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.
Responded
Irene Whittingham
Concerns: Conflicting guidance on Vitamin D and Calcium blood level monitoring for high-dose patients and confusing software interfaces allowed prescribing errors that exceeded national guidelines without GP notification.
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
Mary Nelson
Concerns: Dangerous fluoxetine accumulation suggests a need to revise dosage guidance, especially for the elderly, and consider in-life drug testing. This death was also not reported to the Yellow Card system.
Overdue
Joseph Gingell
Concerns: Permitting "self-certification" for medication without checks, allowing abuse by vulnerable individuals, and not involving the GP removes crucial safeguards, contributing to toxic drug interactions.
Responded
Keith Hill
Concerns: Poor communication between specialists, inadequate medical record-keeping, and insufficient senior support for junior pharmacists resulted in crucial medication decisions not being documented or administered.
Responded
Catherine McNamara
Concerns: Concerns were raised about the initial over-prescription of opiates, leading to dangerously high levels and adverse effects. The impact of these high doses was not adequately understood or managed.
Overdue
Heather Planner
Concerns: Inadequate procedures for communicating and acknowledging medication changes, lack of systems for carers to confirm care plan adherence, and poor record-keeping by the care provider created significant medication error risks.
Overdue
Brenda Drew
Concerns: The deceased received unrequested, repeat prescriptions for high-dose Oramorph. The GP surgery failed to formally review this potent medication for several months, raising concerns about prescribing oversight.
Responded
Matthew Fitten
Concerns: A change in methadone prescription to larger bottles, without providing a measuring jug, likely led to inaccurate dosing and a fatal overdose.
Responded
Dylan Henty
Concerns: Risks included unsupervised bathing for residents with seizure risk, GP unawareness of critical issues like hoarding, failed medication compliance systems, and inconsistent reporting/monitoring for absconding incidents.
Responded
Miriam Tighe
Concerns: Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a care home resident with conflicting medications.
Overdue
Robert Chandler
Concerns: Defective lifting equipment, inconsistent daily checks, incomplete records, and significant delays in implementing internal investigation recommendations posed risks to patient safety and proper incident management.
Responded
Janice Davies
Concerns: Missing documented observations and pain scores before discharge, alongside absent formal guidance for prescribing oramorph to discharging patients, led to inconsistent and potentially inappropriate medication.
Responded
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.
Responded
Cady Stewart
Concerns: Opiate medication from a deceased parent on palliative care was not removed by nursing staff, remaining accessible and subsequently used by the deceased to end her life after a previous suicide attempt.
Overdue
Austin Thomas
Concerns: Drivers of heavy machinery could be distracted by high-volume music, lacking a specific policy. The drug policy was inadequate, with no random testing despite evidence of an employee's drug use.
Overdue
Dawn Gill
Concerns: The patient's long-term illicit drug use was not addressed in a nursing care plan, her methadone drug chart was lost, and there was a concerning delay in locating her despite multiple searches.
Responded
Joseph Page
Concerns: Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which led to an overdose.
Overdue
REDACTED
Concerns: A GP failed to adequately inquire into psychiatric history, made inappropriate medication changes, prescribed excessive quantities, and demonstrated poor record-keeping, missing opportunities for urgent psychiatric referral.
Overdue
Karl Willis
Concerns: "Self-certification" for medication without GP notification allows vulnerable patients with addiction issues to obtain potentially toxic drugs like Amitriptyline unchecked, removing a crucial safeguard.
Responded
Donald Clegg
Concerns: Insufficient care transfers, inadequate pre-admission assessments, and unsafe medicine administration processes, coupled with staff's inability to recognise deteriorating patients and poor record keeping, created significant risks.
Responded
Michalla Sweeting
Concerns: Concerns were raised about inadequate handover procedures for detox patients, including nurses' record review responsibilities and the timing of observations relative to medication administration.
Overdue
Philip Ashton
Concerns: Medication errors occurred due to flawed procedures, staff were unprepared for emergencies, and vital medical history was inaccessible to ambulance crews.
Overdue
Jonathan Earp
Concerns: Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected illicit drug use.
Responded
Barbara Haley
Concerns: Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during meals, contrary to safety assessments.
Overdue
Joan Osborne
Concerns: Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response to deteriorating patient condition and insulin refusal.
Responded
Jean Griffiths
Concerns: A national audit revealed widespread poor oxygen prescribing practices in hospitals, with many patients lacking valid prescriptions, risking inappropriate oxygen levels and increased mortality.
Responded
Mike Fell
Concerns: Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some lines lacking essential clamps, creating a risk of accidental opening.
Responded
James Quinton
Concerns: Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a verbal prescription, highlighting a lack of essential checking procedures.
Responded
David Green
Concerns: The worksite lacked a safe system of work, and there was a widespread practice of employees not wearing seatbelts, with inadequate systems to check compliance.
Overdue
Sandra Miller
Concerns: Urgent action is required to stop unsafe practices with open-ended urinary catheters, establish proper management procedures, and ensure all staff are adequately trained in catheter care.
Overdue
Patrick Moran
Concerns: An insulin overdose occurred due to the common practice of using incorrect syringes, exacerbated by the removal of diabetes from mandatory training and the lack of a system to review compliance with safety alerts.
Overdue
Russell Robb
Concerns: A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding bodies, meant significant police interactions with the deceased were missed, hindering appropriate strategic oversight.
Responded
Stuart Walls
Concerns: The patient died from a synergistic toxic effect of multiple prescribed drugs, each within therapeutic range, affecting the central nervous system and respiration. Prescribing practices need to account for cumulative drug interactions.
Overdue
Ronald Brewer
Concerns: Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.
Responded
Christina Fletcher
Concerns: A lack of clear regulatory guidance on 'red flag' systems for pharmacies to identify patients with similar details and inconsistent chain of custody protocols for controlled drugs pose risks.
Overdue
Jennifer Midgley
Concerns: The drug administration chart fails to clearly distinguish between oral and intravenous paracetamol, lacks patient weight reference for IV dosage, and omits a reminder for weight-modified administration.
Overdue
Christopher Roberts
Concerns: Care plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. Additionally, Nomad trays might be unsuitable for certain patients, impeding medication benefits.
Overdue
Carly Gordon
Concerns: 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.
Responded
Hayley Sheehan
Concerns: The repeat prescription procedure is unsafe as it relies on manual flagging of early requests, with software unable to automatically identify them. More safeguards are needed, including software adaptation.
Responded
Percy Jacks
Concerns: Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led to poor DVT management.
Responded
Songul Bozdag
Concerns: The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to under-medication, with no systemic safety net.
Responded
Patricia Parker
Concerns: Numerous sedation guidelines are not widely known by clinicians, highlighting a need for better training and awareness of sedation risks, especially in the elderly.
Overdue
Kymberley Holden
Concerns: Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management for neurological patients, pose ongoing risks.
Overdue
Lyndsey Holt
Concerns: Methadone was prescribed unsafely over the phone without a face-to-face consultation, leading to a lack of critical patient information and an inappropriate large supply for a methadone-naive individual.
Overdue
Steven Fone
Concerns: The practice of allowing interchangeable prescription collection by different customers without consent raises concerns about potential abuse, stock-piling, and increased risk of harm or death from medication misuse.
Overdue
Daniel Paylor
Concerns: Ambulance services exhibit inadequate regulatory control, safeguards, and auditing for drugs compared to hospitals, lacking sufficient peer supervision and requiring only single-person authority for drug access.
Overdue
Michael Hutchence
Concerns: Concerns included frequent, unnecessary ward transfers, poor medical record-keeping, care by unqualified staff, and inaccurate anticoagulant dosing due to weight recording issues. Equipment shortages and non-sterile surgical kits also caused dangerous operational delays and increased DVT risk.
Responded
Derrick Twiate
Concerns: Dispensing pharmacists continue a practice, contrary to professional advice, of snipping tablets from unit dose packs into multi-dose compliance aids, risking drug integrity and patient safety.
Overdue
Betty Addison
Concerns: A patient at a care home received five additional, unprescribed Dalteparin injections, with no clear explanation for their source or why they were administered.
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.
Responded
Geoffrey Parry
Concerns: Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a lack of clear labelling protocols.
Responded
Lottie Reid
Concerns: There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for checking these errors, especially problematic on weekends.
Responded
Isaac Bahar
Concerns: A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on medication for vulnerable patients.
Responded
Laurence Boyens
Concerns: Systemic failure in adhering to drug administration guidelines, including inadequate blood pressure monitoring, poor record-keeping, and insufficient staff training and awareness regarding signs of patient deterioration for patients on Methadone/Buprenorphine.
Overdue