Unsafe medication management
Failures in the safe management of medicines, including storage, administration, record-keeping, prescribing, and disposal.
454 items
11 sources
1 inquiry
Source spread
Where this theme appears
Unsafe medication management has been flagged across 11 independent accountability sources:
1 inquiry rec
118 PFD reports
3 committee recs
239 CQC actions
17 PPO recs
1 IOPC rec
10 IMB reports
16 IMB recs
1 detention investigation rec
45 PHSO decisions
3 LGO/SPSO 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 (118) — showing 50 strongest matches
Harold Elvidge
Concerns: A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly in non-critical care settings, necessitating a trust-wide review of fluid management.
Overdue
William Kent
Concerns: Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, compounded by unclear usage instructions.
Overdue
Richard White
Concerns: Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.
Response (700 Club2): The 700 Club clarifies that it does not store or administer medication to clients, emphasizing that responsibility for safeguarding clients regarding medication lies with GPs. They will receive medication if …
Responded
Derrick Rivers
Concerns: The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify these critical issues during inspections.
Overdue
Afifa Qaisar
Concerns: Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating systemic clinical procedural shortcomings.
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
Edward Devlin
Concerns: Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks of drug trading or stockpiling for overdose.
Response (Care UK): Care UK will develop a formal policy detailing the action required by nursing staff when they are unable to administer medication to a prisoner, for example due to a threat …
Overdue
Donna Kirkland
Concerns: Patients had unlimited and unsupervised access to alcohol-based hand sanitising gels, enabling decanting and storage in rooms. Staff lacked awareness of the gels' alcohol content and potential for ingestion, posing a significant safety risk.
Response (Coventry and Warwickshire Partnership NHS Trust): The Trust replaced wall-mounted alcohol-based hand sanitiser dispensers with alcohol-free alternatives and raised staff awareness of the risks associated with ingestion of alcohol.
Response (Department of Health): The Department of Health acknowledges the concerns and points to existing national guidance on suicide prevention and risk assessment in mental health services, but doesn't describe specific actions taken or …
Responded
Iris Grimwood
Concerns: Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including incorrect medication application and improper use of medical equipment.
Overdue
Marjorie Phillips
Concerns: The patient's fall from a hoist was attributed to the sling's tendency to "bagging" at the sides, creating a fall risk if the patient shifted their weight.
Response: Sunrise Medical Limited states that their instruction manual is a comprehensive document which deals with the issues of purchase; maintenance and operation of equipment supplied by them, therefore no action …
Overdue
Beatrice Gatt
Concerns: A critical antipsychotic medication was not administered due to a transfer error between medication sheets, highlighting a lack of formal training for nursing staff on medication management.
Overdue
Alan Peck
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
Philip Allen
Concerns: The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist advised stopping it, indicating a risk of medication errors.
Response (Eltham Palace Surgery): The practice conducts twice-weekly ward rounds and medication reviews every 3 months by a prescribing advisor and twice a year by the attending clinician, using electronic prescriptions. They have repeatedly …
Responded
Moses McDonald
Concerns: The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a significant safety concern.
Response (South London Maudsley NHS Trust): The Trust updated its physical healthcare policy to outline the responsibility of clinical staff to address patient's physical health needs and made it mandatory that all patients prescribed anti-psychotic medication …
Overdue
Patricia Edge
Concerns: An excessive paracetamol dose was prescribed and dispensed due to inadequate staff training and procedures, compounded by a failure to review the dose or conduct necessary blood tests.
Response (Bolton NHS Trust): Following an investigation, the Trust identified variations in paracetamol prescribing across the organisation, and the Medical Devices Committee and Medications Safety Group have thoroughly reviewed the prescribing process. The Trust …
Overdue
Andrew Aitken
Concerns: Inadequate management of patient's belongings and medication on admission, failure to seek crucial past psychiatric history, and poor discharge planning for a vulnerable patient without a GP.
Response (Barts Health NHS Trust): The Trust investigated the concerns, interviewing staff and reviewing medical records, finding that tablets left at the bedside were intended to be destroyed by a pharmacist and were locked in …
Response (East London NHS Trust): The Trust will ensure staff are aware that patients can self-refer to the RAID service and is considering how to best communicate this information to all staff working in Tower …
Responded
Leonardus Vries
Concerns: Significant documentary failings and lack of audit for non-controlled medication created opportunities for abuse or theft, highlighting a need for improved internal control measures.
Response (Royal Orthopaedic Hospital): The Royal Orthopaedic Hospital reviewed controls around controlled and non-controlled drugs, updated Standard Operating Procedures for Controlled Drugs, conducted audits and found compliance with required standards.
Responded
Darren Linfoot
Concerns: Non-controlled opiate drugs lacked audit, risking them going unaccounted for. Inconsistent methods for patient observations and radio nurse duties indicated a need for standardized training.
Overdue
Laurence Boyens
Concerns: Healthcare professionals appeared to misunderstand guidelines for managing drug dependence in adult prison settings, particularly around monitoring blood pressure before administering methadone or buprenorphine, and some nurses did not know when to withhold medication or escalate concerns.
Response: Following the PFD report, the GMC commenced a review of their earlier decision not to proceed with a complaint about the doctor's care. They have obtained the doctor's comments and …
Response: The Nursing and Midwifery Council acknowledges receipt of the referral and states that it will go through an initial assessment process to determine how to proceed and will then write …
Overdue
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.
Response (Brighton and Sussex University Hospitals Trust): Brighton and Sussex University Hospitals Trust has discussed the incident with general surgeons and the nursing and pharmacy teams, leading the general surgeons to decide that codeine should no longer …
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.
Response (Birmingham Heartlands Hospitals): Birmingham Heartlands Hospital is piloting new documentation within palliative care for clarity of prescribing. Dissemination of information about the Intermediate Care Procedure to all wards at Good Hope Hospital and …
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.
Response: The University Health Board has reviewed systems for ECG storage, reinforced the use of the MUSE system, and implemented training on intravenous infusion labelling. The learnings from this incident will …
Responded
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
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
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
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.
Response (Stockport NHS Trust): The Trust provides context regarding patient transfers and staffing levels, but does not describe specific actions taken or planned in response to the coroner's concerns.
Responded
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
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
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
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
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.
Response (East London NHS Foundation Trust): The Trust has implemented an inbox-based system to communicate discharge care plans to CMHT staff, and monthly supervision for care coordinators is now working in line with Trust procedures. Regular …
Responded
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
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
Ronald Brewer
Concerns: Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.
Response (Barchester Healthcare): A Deputy Manager with palliative care experience was appointed to support training and practice, staff undertook competency assessments, further training was provided, medication fridges were replaced, and policies/procedures were updated. …
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.
Response (Welsh Government): Healthcare Inspectorate Wales (HIW) has noted the inquest findings and will use the information to inform their ongoing review of discharge arrangements, focusing on communication and documentation between secondary and …
Response (Rhayader Group Practic): Rhayader Group Practice has implemented a system to record and follow up DVT referrals, inform patients with positive DVT results and prescribe Rivaroxiban, and fast-track medical records for new patients …
Response: Hywel Dda Health Board has streamlined the process for managing potential DVT patients with a direct referral pathway to the Radiology Department, a pre-printed letter from on-call physicians to the …
Response (CQC): CQC had no prior knowledge of the death. They contacted Pencombe Hall care home and Cantilupe Surgery in Herefordshire, reviewed information transfer procedures, and consider their current inspection methodology covers …
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.
Response (The Moat House Surgery): The Moat House Surgery requested changes to the EMIS prescribing process to flag early prescription requests and developed a pop-up box alerting staff to prescriptions issued less than 30 days …
Responded
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.
Response (Fremington Medical Centre): The practice has sent personal letters to patients on repeat prescriptions for Benzodiazepines asking them to contact the practice for a medication review. The practice has made a commitment not …
Response (Royal College of General Practitioners): The Royal College of General Practitioners provides context on its role, describes its training and membership offerings, and references existing guidance on benzodiazepine prescribing. It supports a joint consensus statement …
Response (NHS England): NHS England will ask its National Clinical Director for mental health and Head of Mental Health and LD Medicines Strategy to write to medical directors and chief pharmacists in mental …
Response (Devon LMC): Devon LMC will remind practices about the review of patients receiving short-acting Benzodiazepines via its electronic newsletter and will make the information available on its website.
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
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.
Response (Trafford Safeguarding Board): Greater Manchester Police (GMP) now record high volume callers more accurately, and the GMP function that prioritises and allocates cases now sits within the Partnership Office. A revised policy is …
Responded
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
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
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.
Response (Doncaster Bassetlaw Teaching Hospital): Doncaster and Bassetlaw Teaching Hospitals are training individuals as scribes, obtaining a software update for monitors, and have set up a working group with ED and Anaesthetics to explore the …
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.
Response (Department of Health): The Department of Health acknowledges concerns regarding oxygen prescribing practices. NICE is updating its guideline CG101 to tighten prescribing practice and the BTS and Royal Colleges will have opportunity to …
Responded
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.
Response (Adbolton Hall Ltd): Adbolton Hall outlines several actions already implemented, including appointing a new Home Manager, providing diabetes awareness training to staff, purchasing new blood glucose monitoring machines, removing Lucozade from the premises, …
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
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.
Response (Royal College of Anaesthetists): The RCoA will publish information on central venous access line safety in the Patient Safety Update and include these issues in the updated AAGBI guideline Safe Vascular Access. The FICM …
Response (Barts NHS Trust): Barts NHS Trust has rewritten its policy on the use of central lines and three-way taps, stating that three-way taps should not be used on central lines but self-sealing injection …
Responded
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.
Response (Gloucestershire Hospitals NHS Trust): The Trust reviewed the circumstances of fentanyl administration, discussed the case with ward staff and presented it to the Senior Nurse and Midwifery Committee. An action plan confirms work undertaken …
Responded
Committee Recommendations (3)
#168 — Implement new secure systems for distributing and administering prison medication to prevent diversion.
Recommendation: HMPPS should conduct an urgent review of all prescription medication dispensing procedures within prisons to identify and close loopholes exploited for diversion and introduce enhanced supervision of medication queries. New secure systems for distributing and administering medication must be implemented …
Gov response: Staff training in emergency medical responses is a vital part of safeguarding within prisons. MoJ, HMPPS and NHSE will work in partnership to deliver training to ensure all frontline staff are appropriately trained and able …
Partially Accepted
#24 — Commission independent review into hospital medicines management, focusing on automation and digital systems.
Recommendation: We recommend that an independent review is commissioned to explore hospital medicines management, to report within one year. The review should make recommendations, particularly around how the potential of automation and technological systems like connected medication management could be realised …
Gov response: Partially Accept This Government inherited a system that has been neglected for too long. We are committed to exploring opportunities to make use of technology as we look to develop and support our NHS in …
Partially Accepted
#23 — Strategic oversight lacking for widespread adoption of automation in hospital medicines management.
Recommendation: There are clearly benefits to be found from using automation and technology particularly within hospital medicines management. These benefits could unlock gains in productivity, improve patient safety and free up pharmacist time to work more directly with patients. There are …
Gov response: Partially Accept This Government inherited a system that has been neglected for too long. We are committed to exploring opportunities to make use of technology as we look to develop and support our NHS in …
Partially Accepted
CQC Inspection Actions (239) — showing 50 strongest matches
Chy Byghan Residential Home
The provider must ensure people who use services are protected against the risks associated with unsafe management of medicines and insufficient medicines stocks.
Must Do
Brook House Residential Home
Make improvements regarding the administration timings of time critical and pain relief medicines.
Must Do
Assured Care Formby
Medicines were not managed safely. Risks to people were not adequately assessed or managed to keep people safe from avoidable harm. Care plans were not in place or not sufficiently detailed to mitigate the risks to people's health and welfare.
Must Do
Aaron Abbey Care Services Limited
The registered person must ensure that care and treatment is provided in a safe way for service users, and ensure the proper and safe management of medicines.
Must Do
We Can Recover CIC
Training records provided recorded only two of the four registered nurses had completed medicine administration training. The process around clinical oversight and supervision of registered nurses in medicine management remained unclear. The service had not implemented a safe system and …
Must Do
Verve Health
The service must ensure they use systems and processes to safely prescribe, administer and record medicines and that the clinic room and medication is secure.
Must Do
Valewood House Nursing Home
People were not protected against the risks associated with the unsafe use and management of medicines.
Must Do
Trent Lodge Residential Care Home
The provider must ensure service users and others are protected against the risks associated with the unsafe storage of medicines.
Must Do
St Paul's Lodge
The registered person did not have suitable arrangements in place to ensure people who used the service received their medicines as prescribed.
Must Do
Reside at Southwood
The provider must ensure that people are protected against the risks associated with the unsafe management and use of medicines.
Must Do
Redcot Lodge Residential Care Home
The provider must do all that is reasonably practicable to mitigate risk and ensure the proper and safe management of medicines.
Must Do
Oaklands Care Home
The provider failed to ensure people's medicines were managed safely.
Must Do
Manor House Care Home
People were not fully protected against the risks associated with medicines because the provider did not manage medicines appropriately.
Must Do
Haisthorpe House
The provider must ensure people who used services are protected against the risks associated with unsafe use and management of medicines.
Must Do
Epilium & Skin
The service must implement and maintain consistent, safe medicines management. This must include safe procedures in line with national requirements that include storage, stock management, prescribing, administration, and destruction.
Must Do
Brushwood
Systems in place had failed to ensure medicines were managed safely.
Must Do
Bindon Residential Home
The provider must ensure the safe management of medicines.
Must Do
Benthorn Lodge
The registered person had not protected people against the risk of unsafe management of medicines. The systems in place to ensure medicines were administered safely were not consistently followed.
Must Do
Worcestershire Imaging Centre
The provider must ensure medicines stored within the service are in date and safe for use.
Must Do
Westwood Care Home
The provider failed to ensure proper and safe management of medicines. This is a continued breach of regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 12(2)(g)
Must Do
Voyage(DCA) Greater Manchester
The provider must ensure people's medicines are always managed safely.
Must Do
Unit 4 Cornishway Industrial Estate
Provide care and treatment in a safe way for service users by ensuring the proper and safe management of medicines. Staff responsible for the management and administration of medication must be suitably trained and competent and this should be kept …
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
The Long Brook Residential Home
The provider failed to store people's medicines safely or established safe processes to manage people's medicines.
Must Do
The Lilacs Residential Home
The provider must ensure that medicines are managed safely. This is to ensure people receive their medicines as prescribed.
Must Do
The Hollies Care Home
Appropriate arrangements for the safe administration and storage of medicines were not in place.
Must Do
The Goddards
The provider must ensure staff follow relevant guidance to ensure proper and safe management of medicines.
Must Do
The Beacon
The provider had failed to ensure the proper and safe management of medicines.
Must Do
TerraBlu Homecare
Registered persons had failed to take appropriate actions to ensure medicines were managed in a safe way.
Must Do
Suite 4, Jason House
The provider must ensure proper and safe management of medicines.
Must Do
Slate House Residential Home
The provider must ensure appropriate arrangements are in place for administering medicines to protect people against the risks associated with unsafe use and management of medicines.
Must Do
Shire Oak House
No system in place to ensure medication was ordered for step down bed service users
Must Do
Shining Star Home Care Limited
Improvements were needed in the record keeping of medicines which were administered to people.
Should Do
Shenstone Hall Nursing Home
The provider must ensure that medicines are managed effectively, including accurate recording of stock and proper countersigning of changes to Medicines Administration Records (MAR).
Must Do
Russell Churcher Court
The provider must ensure that care and treatment is provided in a safe way for service users, specifically regarding the safe management and administration of medicines.
Must Do
Ridgeway Manor Residential Care Home
People's medicines were not managed properly and safely.
Must Do
Ransdale House
The provider must have systems in place to ensure medicines are always safely managed and ensure that governance and quality monitoring of the service are robust enough to ensure people are protected from the risk of harm.
Must Do
Priority Care Home
The provider had failed to ensure the proper and safe management of medicines
Must Do
Pelham House
The provider must begin monitoring the temperature of the dedicated room where medicines are stored to ensure all medicines are being stored at an appropriate temperature.
Must Do
Pelham House
The provider must ensure the temperature of the medicines fridge is monitored appropriately.
Must Do
Oak Tree Lodge
Systems were not robust enough to demonstrate medicines were effectively managed.
Must Do
Newland House
There were not adequate systems in place for medicines management. As a result people's medicines were not always administered correctly.
Must Do
Mulberry Court
The provider had not ensured there were sufficient quantities of medicines available to ensure the safety of service users and to meet their needs.
Must Do
Marillac Neurological Care Centre
The provider was not ensuring the proper and safe management of medicines
Must Do
London Hair Transplant Clinic
The service must ensure medicines are managed safely. They must ensure all medicines are in date, stored securely and labelled appropriately(Regulation12(2)(g)).
Must Do
Laburnum Court Care Centre
The provider must ensure that systems, processes and record keeping relating to the management of medicines are robust.
Must Do
Kings Den
Proper and safe use of medicines had not always been followed.
Must Do
Keyznow Health and Social Care Ltd
Medicines were not managed and administered safely.
Must Do
Keb House Residential Home
The provider had failed to ensure the proper and safe management of medicines.
Must Do
James Nugent Court
Medicines were not being managed safely.
Must Do
PPO Death in Custody Recommendations (17)
The Head of Healthcare
The Head of Healthcare should ensure the local operating policy for managing omitted doses of medication is reviewed and includes more specific and clearer guidance to the Pharmacy Team on the management (including when to alert the GP) of in-possession …
The Head of Healthcare
The Head of Healthcare should rewrite the Medications in Possession document as a Standard Operating Procedure (SOP), which should include: • A system to monitor that a prisoner is taking medications as prescribed. • A medical review to be triggered …
The Head of Healthcare
The Head of Healthcare should ensure that all staff who undertake Medication in Possession Risk Assessments (MIPRA) follow the Spectrum Medicines in Possession policy and review the prisoner’s medical record as part of their assessment.
The Head of Healthcare and the lead pharmacist
The Head of Healthcare and the lead pharmacist should ensure that there is an effective system in place so that prisoners who return to prison late receive their medication.
The Head of Healthcare
The Head of Healthcare should review the treatment policy and management of methadone, including assessing the need for ECG tests when starting methadone and additional monitoring when dosage is significantly increased.
The Head of Healthcare
The Head of Healthcare should investigate why one of Mr Francis’s medications was not prescribed when he arrived at Dovegate and introduce any changes necessary to prevent a recurrence of this issue.
The Head of Healthcare
The Head of Healthcare should review processes to ensure prescribed treatments are effectively administered and issues are promptly resolved.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that prisoners who are not taking or collecting their medication are identified and reviewed, and that prisoners choosing to isolate are able to safely collect and take their medication.
The Head of Healthcare
The Head of Healthcare should establish a system for medication reviews with prisoners who fail to collect their medication on several occasions.
The Head of Healthcare
The Head of Healthcare should ensure that medication in possession arrangements are reviewed and audited so that appropriate safety measures are in place to identify and address non-compliance with medication promptly.
The Governor and Head of Healthcare of HMP Bedford
The Governor and Head of Healthcare should introduce a robust audit process to ensure that when a prisoner is suspected to be under the influence staff understand and follow the protocol.
The Governor and Head of Healthcare of HMP Bedford
The Governor and Head of Healthcare should review whether the current medication administration process is sufficiently robust and identify any weaknesses to minimise the risk of diversion.
The Director of HMP Parc
The Director should ensure that officers supervise medication queues appropriately to limit opportunities for diversion of medication.
The Head of Healthcare
The Head of Healthcare should ensure that when a prisoner does not receive their medication, healthcare staff record the reason on the prisoner’s medications history sheet.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that the relevant risk assessments are undertaken regarding the possession of medication, where a prisoner overdoses.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that pharmacy teams are notified when ACCT procedures are started and that they complete an in-possession medication risk assessment.
The Governor and Head of Healthcare
When ACCT monitoring is started, healthcare staff assess a prisoner’s risk to determine whether he should continue to keep and administer prescribed medication.
IMB Annual Reports (10)
Stafford (2021)
This IMB annual report for HMP Stafford, a Category C training prison, covers a period significantly impacted by the Covid-19 pandemic. Key concerns include persistent poor medicines management, deteriorating staff-resident relationships, and the challenges of a highly restrictive regime compounded by a lack of in-cell telephony. Positive aspects noted were low violence and drug levels, successful vaccine rollout, and comprehensive in-cell activity provision.
PRISON
Key concerns
Stafford (2022)
HMP Stafford, a Category C training prison for men convicted of sexual offences, navigated significant challenges during the reporting period, primarily systemic failures in medicines management, Covid-19 outbreaks, and staff shortages impacting the regime. While the Board noted severe concerns regarding healthcare and the lack of in-cell phones, it commended staff resilience, low violence levels, good education attendance, and effective resettlement efforts, particularly in securing accommodation for released residents.
PRISON
Key concerns
North West and Midlands STHF (2023)
The Board has resumed actual visits to most locations, with two exceptions, and consists of three active members who continue their duties robustly, despite being under-strength. Key concerns include the persistent issue of detainees being denied access to prescribed medication in facilities without full-time medical professionals, and the slow rectification of structural and equipment deficiencies. Positive developments include the resolution of airside pass issuance and observations of humane and professional treatment of detainees.
PRISON
Key concerns
North East Midlands, Yorkshire & Humber STHF (2023)
This is the first annual report for the North East Midlands, Yorkshire & Humberside IMB, covering Short-Term Holding Facilities (STHFs) from February 2022 to January 2023. While staff conduct and detainee treatment generally received positive feedback, significant concerns arose regarding the unsafe opening and managing large intakes at Swinderby Residential STHF. The Board also highlighted the critical and unresolved issue of Home Office policy preventing detainees in all STHFs from taking prescribed medication, deeming it inhumane and dangerous.
PRISON
Key concerns
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)
The Scotland and Northern Ireland STHF IMB report highlights generally humane treatment by staff but identifies significant concerns across multiple facilities for the period February 2022 to January 2023. Key issues include the unsafe removal of prescription medication, inadequate disability provisions, and the unsuitability of airport holding rooms for increasingly prolonged detentions. The Board also notes long-overdue building alterations at Larne House and ventilation issues across the estate, urging urgent action from the Home Office and facility managers.
PRISON
Key concerns
Wymott (2021)
HMP Wymott largely maintained safety during a challenging Covid-19 reporting year (June 2020-May 2021), seeing reductions in self-harm and violence. While staff efforts and some initiatives were commendable, the pandemic exacerbated long-standing issues, particularly with healthcare provision, the prison estate's infrastructure, property loss, and complaints handling. The restricted regime severely limited opportunities for purposeful activity, education, and resettlement, causing significant frustration among prisoners.
PRISON
Key concerns
Wandsworth (2021)
HMP Wandsworth operated under severe COVID-19 restrictions for most of the year, leading to prisoners spending up to 23.5 hours a day in cramped cells. The prison remained highly overcrowded and faced significant safety challenges from violence and widespread drug availability. Persistent concerns include the inhumane state of the Victorian buildings, inadequate healthcare facilities, rising mental health needs, and the absence of Home Office immigration support.
PRISON
Key concerns
Thameside (2021)
HMP Thameside operated under a Covid-19 lockdown regime for much of the reporting year, successfully containing the virus but impacting prisoner welfare. The prison transitioned to a restricted regime, and introduced proactive safety management initiatives, including a revised approach to gangs. However, key concerns persist regarding the long-term effects of confinement, delays in mental health transfers, staffing shortages, and insufficient purposeful activity. The IMB also highlights issues with medication dispensing, the healthcare complaints system, and facilities management.
PRISON
Key concerns
Styal (2022)
HMP/YOI Styal successfully managed Covid-19 spread and saw a significant reduction in self-harm, with healthcare and perinatal care provision improving. However, the Board highlighted critical staffing shortages impacting regime and services, persistent decency and fire risks in residential houses, and challenges in managing prisoners with severe mental health needs. Concerns were also raised regarding medication administration, changes to resettlement contracts, and the distress caused by the parcel ban.
PRISON
Key concerns
Thameside (2022)
HMP Thameside, a Category B/C prison, saw its population close to its operational capacity of 1,232. While the regime slowly normalized after Covid restrictions, challenges persisted, including a rise in prisoner-on-prisoner assaults (273 total) despite a decrease in staff assaults (168 total). The Board identified significant concerns around the inhumane delays for mental health transfers (average 39 days), inadequate property handling (complaints up 60%), and the unreliability of the cell bell system. Staff shortages, particularly impacting purposeful activity and resettlement services, were partially mitigated by recruitment efforts, though a large cohort of inexperienced staff remains.
PRISON
Key concerns
IMB Recommendations (16)
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
Buckley Hall (2021)
Provide secure medication in-cell facilities (6.1.14)
HMPPS
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
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
Stafford (2022)
Sustained effective healthcare and medicines management that delivers for the residents of HMP Stafford and not just PPG targets
HMPPS
London STHF (2023)
Eaton House and City Airport urgently need a workable solution for administering personal medication. This issue has been raised for many years now.
Other
London STHF (2024)
Eaton House and London City Airport urgently need a workable solution for administering personal medication. This issue has been raised for many years now, including at Ministerial level.
Home Office
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
Lewes (2023)
Will the Governor ensure that all prison staff are aware of the importance of supervising dispensary hatches?
Governor / Director
Styal (2025)
What progress is being made to ensure adequate and secure ‘in-possession meds’ lockers in the houses and on the wing?
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2025)
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 …
Ministry of Justice
London short term holding facilities (STHF) (2025)
Eaton House and London City Airport urgently need a workable solution for administering personal medication. This issue has been raised for many years now, including at Ministerial level.
Ministry of Justice
South and East Short Term Holding Facilities (STHF) (2025)
The Board recommends that the Minister review the accommodation capacity, especially as noted in 4.3 and 5.1 at Luton and Stansted. There are an increasing number of people held overnight at the STHFs, which are not designed for overnight accommodation and, in some places, do not provide a dignified and humane space and where the only hot food available at …
Other
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
PHSO Casework Decisions (45)
P-001367 — Northern Lincolnshire and Goole NHS Foundation Trust
Mr H complained the Trust should not have given diazepam to his mother covertly and against her wishes. He also complained diazepam was an unsuitable medication because it slowed his mother’s breathing and contributed to her death an hour later.
NHS in England
Apr 2022
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-001329 — The Dudley Group NHS Foundation Trust
Mrs O complains that the Dudley Group NHS Foundation Trust did not administer her late husband's medication correctly, did not monitor his nutrition and made him use continence pads.
NHS in England
Mar 2022
P-001589 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Miss W complains about antidepressants the Trust and Practice prescribed. She complains they did not prescribe this medication safely
NHS in England
Partly Upheld
Sep 2022
P-001825 — A practice in the Cheshire area
Mrs G complains the Practice stopped her mother’s blood thinning medication without doing a physical examination first.
NHS in England
Feb 2023
P-001900 — The Chaseley Trust
Mrs R complains about the care and treatment provided by a care home funded by the Trust. She says it gave her too much antibiotic cream for her eyes, did not give her eye drops properly and did not communicate details of her hospital appointment.
NHS in England
Mar 2023
P-001863 — Leicestershire Partnership NHS Trust
Ms L complains the Trust's district nursing team did not give her mother medication and did not respond when the family tried to contact it.
NHS in England
Mar 2023
P-001894 — Manchester University NHS Foundation Trust
Ms R complains the Trust failed to manage her mother’s pain medication in the days leading up to her death. She also says the Trust’s poor communication led to her feeling confused about her mother’s care.
NHS in England
Mar 2023
P-002287 — Solent NHS Trust
Mrs M complains staff from the Trust failed to make sure her father had a good supply of medication for pain relief in the days before his death.
NHS in England
Upheld
Nov 2023
P-001335 — Oxford Health NHS Foundation Trust
Mr R complained about how the Trust managed his treatment, and how it monitored and administered his olanzapine.
NHS in England
Mar 2022
P-001522 — A medical practice in the Surrey area
Mrs I complains about the medication the practice prescribed to her mother
NHS in England
Sep 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-002250 — British Pregnancy Advisory Service
Miss A complains the British Pregnancy Advisory Service gave her abortion medication without legal and proper consultation. She also complains about how it handled her complaint.
NHS in England
Oct 2023
P-002480 — Manchester University NHS Foundation Trust
Mr C complains that in January 2022 the Trust prescribed steroids for an eye condition but did not tell him about all the possible side effects. He says this meant he was not able to make an informed decision about whether to take the steroids.
NHS in England
Upheld
Nov 2023
P-002310 — A practice in the Birmingham area
Mr A complains the Practice failed to explain the potential side effects of the B12 injections it treated him with. He also complains he did not need the injections and should not have been given them.
NHS in England
Nov 2023
P-002333 — University Hospitals Birmingham NHS Foundation Trust
Mrs O complains about the Trust's care of her sister. She says it gave her medication that was not right for her condition, decisions were made without consulting the family and a diagnosis was made without doing any tests.
NHS in England
Nov 2023
P-002787 — A practice in the Manchester area
Miss V complains the Practice incorrectly prescribed her antibiotics for a cough without doing a physical examination first.
NHS in England
Jul 2024
P-002764 — West Suffolk NHS Foundation Trust
Mrs C complains the Trust inappropriately prescribed a strong anti-psychotic medication to her husband during his admission from September to November 2020.
NHS in England
Not Upheld
Jul 2024
P-003032 — Surrey and Sussex Healthcare NHS Trust
Mrs A complains about the Trust’s care and treatment between July 2022 and July 2023. Mrs A says she was given the incorrect blood type by transfusion, a surgical drain was left in her stomach after a Caesarean section and a consultant left an inappropriate voicemail regarding the results of …
NHS in England
Oct 2024
P-003516 — Barnsley Hospital NHS Foundation Trust
Mr L complains about the care the Trust gave to his wife in August and September 2023. He complains about the medication prescribed, that doctors did not act quickly enough and that staff wrongly recorded she was allergic to flucloxacillin antibiotics.
NHS in England
Apr 2025
P-003604 — Frimley Health NHS Foundation Trust
Mrs J complains the Trust did not correctly handle her mother’s antibiotics between 12 and 15 November 2022. Mrs J also complains the Trust failed to correctly administer her mother’s Parkinson’s disease medication.
NHS in England
Jun 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-003729 — Portsmouth Hospitals University NHS Trust
Mr O complains about the inpatient care his wife received from the Trust from May to July 2021. This included premature discharge, inappropriate medication management and poor record keeping.
NHS in England
Upheld
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-004433 — Barts Health NHS Trust
Dr G complains about the treatment provided to her son, Mr K. She says that Mr K was not given his medication or any food while on the mental health inpatient ward. She also says that he was unnecessarily sectioned.
NHS in England
Nov 2025
P-001758 — Calderdale and Huddersfield NHS Foundation Trust
Mrs E complains the Trust delayed her father's treatment and did not manage his medication properly before surgery. She also complains it did not deal with her complaint well or recognise what the family has gone through.
NHS in England
Jan 2023
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-002285 — A pharmacy in the Greater London area
Ms A complains the Pharmacy did not tell her when it was giving her different brands of thyroxine (medication to treat an underactive thyroid gland) between February and November 2022. Ms A says she had a reaction to ingredients in some of the brands and experienced side effects like hives, …
NHS in England
Nov 2023
P-002814 — A dental practice in the City of Brighton …
Ms A complains the Practice failed to investigate her complaints of sensitive teeth and inappropriately gave her antibiotics.
NHS in England
Partly Upheld
Jul 2024
P-003071 — University Hospitals of North Midlands NHS Trust
Mrs C complains that when her husband was admitted in October and November 2022, the Trust failed to manage his eating and nausea, gave him midazolam, spoke insensitively to him about end-of-life care and failed to call her before he died.
NHS in England
Oct 2024
P-003495 — East Sussex Healthcare NHS Trust
Miss I complains about the care and treatment she received from the Trust in April 2023 for a broken wrist and hip, and she complains about being over prescribed medication during this same admission.
NHS in England
Apr 2025
P-003636 — Manchester University NHS Foundation Trust
Mrs U complains her father, Mr L, was not adequately supervised in hospital and received fluids in an unsafe way. She also complains about medication not being stopped, and delays in inserting a feeding tube.
NHS in England
Partly Upheld
Jun 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-004419 — Greater Manchester Mental Health NHS Foundation Trust
Mrs A complains about the discharge process and the lack of medication reviews prior to discharge.
NHS in England
Nov 2025
P-004422 — Calderdale and Huddersfield NHS Foundation Trust
2. Mrs P has raised a number of concerns about her husband’s care and treatment which include: concerns about his fluid and nutrition intake, feeding tubes becoming blocked, her husband not being weighed appropriately, being placed on an inappropriate ward, and involving security due to her husband’s behaviour. She also …
NHS in England
Dec 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-003889 — United Lincolnshire Hospitals NHS Trust
Miss A complains the Trust allowed her father to eat a sandwich during a discharge assessment despite him being on a thick liquid diet because of an oesophageal condition.
NHS in England
Jul 2023
P-003079 — Guy's and St Thomas' NHS Foundation Trust
Mr P complains about how the Trust managed his daughter’s feeding tube.
NHS in England
Oct 2024
P-003167 — A practice in the Bradford area
Mrs O complains the Practice's care and treatment in October 2023 when she attended for a steroid injection in her wrist for carpal tunnel syndrome.
NHS in England
Nov 2024
P-003171 — A practice in the Brent area
Ms F complains about the treatment she received at the Practice whilst having a tetanus vaccination on 6 February 2024.
NHS in England
Nov 2024
P-003633 — Mid Yorkshire Teaching NHS Trust
Miss A raised concerns about the Trust’s care of her mother, including a failure to diagnose her symptoms, inappropriate medication, lack of ICU transfer, and inadequate airway management.
NHS in England
Jun 2025
P-003608 — University Hospitals of Leicester NHS Trust
Mrs A complains about the care and treatment provided to her mother-in-law by the Trust and Practice between 2023 and 2024. Mrs A complains about the surgery and medication for her mother-in-law's gallbladder and clostridium difficile condition.
NHS in England
Jun 2025
P-003620 — Nottingham University Hospitals NHS Trust
Mr F complains about the care and treatment provided to his aunt in August 2022. He says the Trust failed to ensure her iron infusion was carried out safely and to prevent her condition deteriorating.
NHS in England
Not Upheld
Jun 2025
P-004070 — Sandwell and West Birmingham Hospitals NHS Trust
Mrs D complains about the care and treatment her brother, Mr A, received from the Trust in late 2021/early 2022. She complains about treatment, medication and discharge decisions.
NHS in England
Partly Upheld
Sep 2025
P-004439 — The Princess Alexandra Hospital NHS Trust
Mr P complains the Trust failed to provide appropriate bed care, investigations and treatment and pain medication to his late mother-in-law Mrs K. He also says the Trust unsafely discharged her when it realised it has inappropriately given her, end-of-life medications.
NHS in England
Dec 2025
LGO / SPSO Decisions (3)
24-006-336 — Promedica24 (Lancashire) Limited
Summary: Mr A complained that the care provider failed to keep his mother Mrs X safe in her home. In particular he complains that the live-in carer was unaware Mrs X had left the house alone in the night, or had put liquid soap in her own food. The evidence …
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2025
21-016-847 — London Borough of Barnet
Summary: Ms X complains about poor care provided to her mother, Ms Y, and poor communication from a Council-commissioned home care provider between June 2021 and February 2022. She said the poor care and poor communication have caused her and her mother distress. The Council was at fault. The care …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
25-002-305 — Sanctuary Care Limited
Summary: We will not investigate Mrs X’s complaint, made on behalf of Mrs Y, about how care home staff dealt with the loss of Mrs Y’s jewellery and changed her carer. Investigation of the jewellery matter would not add to the investigations by the Care Provider and the police nor …
LGO (Local Government & …
Adult Care Services
Aug 2025