New Public Interest report issued today has found that a series of failures in medication prescribing and checking, and poor communication between medical and pharmacy teams, led to a patient being mistakenly issued with morphine sulphate on discharge from hospital. The patient died of a morphine overdose 2 days later. He had been supplied with a controlled drug without being made aware of the risks or given guidance on safe use, significantly increasing the risk of accidental overdose and resulting in an extremely serious injustice.
The Complaint
We launched an investigation after Mrs P complained about care provided by Betsi Cadwaladr University Health Board to her late husband, Mr P, at Wrexham Maelor Hospital in March 2024.
The investigation considered whether it was clinically appropriate to prescribe Sevredol (morphine sulphate) to Mr P and whether he and his family were provided with sufficient information and support to minimise the safety risks associated with the prescription.
What we found
We upheld both complaints.
The investigation found that Mr P was mistakenly issued morphine sulphate on leaving hospital. The prescribing consultant had prescribed the medication for use in hospital only and believing, wrongly, that Mr P had been taking it before admission.
There was a series of failures by the medical and pharmacy teams to carry out expected checks which would have identified this error. These failings were compounded by poor communication and a lack of effective multidisciplinary working. As a result, the medication was issued against the prescriber’s intentions.
There was also a failure to document appropriate clinical reasons for the prescription, given that opioids are not recommended for migraine or headache treatment under relevant guidance.
Mr P was given a controlled medication without being made aware of the risks or given guidance on safe use, including the risk of potentially fatal unintentional overdose. We concluded that it was not safe to provide Mr P with Sevredol in these circumstances.
Tragically, Mr P died of a morphine overdose 2 days later. While it was not possible to determine whether the hospital supply directly caused his death, supplying morphine sulphate in error, without appropriate advice, significantly increased the risk of accidental overdose. This was an extremely serious injustice to Mr P and his family.
We noted that patient safety should always be the priority and that the desire to arrange prompt discharge may have contributed to insufficient attention to the safety of the prescription.
The Health Board missed opportunities to identify and address these failings during its own investigation. The investigation was not sufficiently robust or objective and did not obtain independent medical advice which would likely have identified the failings. Complaint handling fell well short of the Duty of Candour.
This is the second successive public interest report involving the Health Board to identify shortcomings in relation to the Duty of Candour.
Commenting on the report, Public Services Ombudsman for Wales, Michelle Morris, said:
“This case highlights a series of failures in prescribing, checking and communication which led to a patient being supplied with a controlled drug in error. This represents an extremely serious injustice to Mr P and to his family. These failings should have been identified and addressed at an earlier stage.
I am also concerned that the Health Board has again fallen short of the Duty of Candour, and I expect it to ensure that the spirit and requirements of the Duty are fully embedded in everyday practice.
I am issuing this report as a public interest report to ensure that the Health Board publicly demonstrates how it has learned from the failings identified, the action it is taking in response to them and to provide reassurance that similar failings will not occur in future. I also consider it important that lessons are learned more widely across NHS Wales, and that other health boards review their own arrangements to ensure that robust processes are in place.”
Our Recommendations
We made a number of recommendations, which Betsi Cadwaladr University Health Board accepted. These included:
- Apologising to Mrs P and making a financial redress payment to her for issuing Sevredol without ensuring it was safe, and for failing to provide appropriate advice about the risks of its use
- Sharing learning points with all medical and pharmacy staff, and reminding them of their responsibilities under relevant guidance
- Carrying out a full review of processes and practices within medical and pharmacy teams.