Mrs P complained about care provided by the 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 Mr P and his family were provided with sufficient information and support to minimise the safety risks associated with the prescription of Sevredol.
Both complaints were upheld. The investigation found that Mr P was mistakenly issued with morphine sulphate on leaving hospital. The prescribing doctor had prescribed the medication for use in hospital only and did so believing, wrongly, that Mr P had been taking the medication before his admission. There was a series of failures to carry out expected checks which would have identified this error. This was compounded by poor communication by the medical and pharmacy teams. The result was that Mr P was given a controlled medication without being made aware of the risks and without any guidance on how to take it safely.
Tragically, Mr P died of a morphine overdose 2 days later. The investigation found that supplying Mr P with morphine sulphate in error without appropriate advice and guidance significantly increased the risk that he would suffer an accidental overdose. This was an extremely serious injustice to Mr P and to his family.
The Ombudsman was also concerned that the Health Board had missed opportunities to acknowledge and address the seriousness of the communication and process failings which led to the prescription error.
This was not in keeping with the Health Board’s obligations under the Duty of Candour which requires NHS Wales organisations to be open with service users when things go wrong.
The Ombudsman noted that this is the second successive public interest report she has issued involving the Health Board which has identified shortcomings in relation to the Duty of Candour. The Ombudsman said she would expect the Health Board to take this opportunity to ensure that the requirements and spirit of the Duty of Candour are fully embedded in the culture and daily practice of its clinical and complaints teams.
The Health Board agreed to the Ombudsman’s recommendations to:
a) Apologise to Mrs P for the failings identified in this report, and in particular, for issuing Mr P with Sevredol without ensuring that it was safe and failing to provide him with appropriate advice about the risks of its use.
b) Make a financial redress payment of £2000 to Mrs P to reflect the injustices caused to Mr P and his family by these failings.
c) Share the learning points from this case (in fully anonymised form) with all medical and pharmacy staff and remind them of their responsibilities in accordance with the NICE controlled drugs guidance, and the Health Board’s Medicines Policy. This communication should highlight the importance of documenting the clinical rationale for prescriptions, and emphasise that the safe prescription of medication should be prioritised, and that clinicians should consider delaying discharge or not providing medications if necessary to achieve this. It should also urge them to make every effort to counsel patients prior to discharge about their medicines, prioritising those patients on high-risk medicines like opioids and anticoagulants and those prescribed new medicines.
d) Share this report with the Consultant for the purposes of reflection as part of continual professional development and for consideration at their next annual appraisal.
e) Share this report with the Health Board’s complaint investigation team to review the conduct of its investigation in line with the Duty of Candour and identify learning points to ensure that similar failings are not missed in the future. Any improvements it identifies should be fed back into its complaints handling procedure and shared with my office.
f) Share this report with the Health Board’s Quality and Patient Safety Committee to consider my findings and include its learning from these recommendations in its Annual Duty of Candour report.
g) Carry out a review of process and practice within the medical and pharmacy teams to address all the failings identified in this report. The review should be coordinated with the involvement of senior management and the medical directors within the relevant directorates. It should:
• Investigate and provide assurance that all prescriptions are subject to all appropriate checks and enquiries by the prescriber and by the pharmacist on the ward (see paragraph 43), and where this is not possible that the same steps are carried out by a pharmacist prior to discharge
• Identify actions to improve multiprofessional working and communication between the medical and pharmacy teams
• Consider whether the process for completing an interim discharge summary should be amended to include information about whether the prescription was new, or pre admission
• Identify and address barriers to clinicians accessing information about prescriptions from GP practices in England
• Consider whether DMRs are being used where appropriate, and to address any barriers to their use for cross-border patients.
As part of the review, the Health Board should conduct an audit of randomly selected discharges from the AMU from the past 6 months to determine whether the prescriptions provided on discharge were subject to appropriate checks in accordance with relevant internal and external standards. The Health Board should provide the Ombudsman with the outcome of the review and the audit along with an action plan to address any instances of non-compliance identified during the audit.