Public interest report: Betsi Cadwaladr University Health Board (202501841)

This report is issued under s.23 of the Public Services Ombudsman (Wales) Act 2019.

We have taken steps to protect the identity of the complainant and others, as far as possible. The names of the complainant and others have been changed as well.

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 and Quality and Risk Committees 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.

1. Mrs P complained about care provided by Betsi Cadwaladr University Health Board (“the Health Board”) to her late husband, Mr P, at Wrexham Maelor Hospital (“the Hospital”) in March 2024. The investigation considered whether:

• it was clinically appropriate to prescribe Sevredol (morphine sulphate) to Mr P
• Mr P and his family were provided with sufficient information and support to minimise the safety risks associated with the prescription of Sevredol.

2. My investigator obtained comments and copies of relevant documents from the Health Board and considered those in conjunction with the evidence provided by Mrs P. They also obtained professional advice from 2 professional advisers, Dr Salim Cheeroth, a consultant in acute and geriatric medicine (“the General Physician Adviser”) and Ms Dianne Burnett a clinical pharmacist (“the Pharmacist Adviser”).

3. Both Mrs P and the Health Board were given the opportunity to see and comment on a draft of this report before the final version was issued.

4. The investigation considered the following guidance issued by the General Medical Council (“the GMC”):

• The GMC “Good practice in proposing, prescribing, providing and managing medicines and devices”, last revised March 2022 (“the GMC Prescription Guidance”). This states at paragraph 26 that clinicians must not prescribe medicines if they do not have sufficient information about the patient’s health.  It also states that clinicians must consider whether the information they have is sufficient and reliable enough to enable them to provide safe care.  They should consider whether they have access to the patient’s medical records or other reliable information about their health and other treatments they are receiving.  With reference to the prescription of controlled medications, it states at paragraph 59: “If you don’t have access to relevant information from the patient’s medical records you must not prescribe controlled drugs or medicines that are liable to abuse, overuse or misuse or when there is a risk of addiction and monitoring is important”.
• The GMC “Good Medical Practice”, 2024 (“the GMC Good Practice Guidance”) (paragraphs 69-71), “Recording your work clearly, accurately, and legibly”. This outlines the requirements for clear and accurate records and provides guidance about the level of detail that should be included in a patient’s records.

5. The investigation considered the following guidance issued by the National Institute for Health and Care Excellence (NICE):

• NICE Clinical Guideline CG150 “Headaches in over 12s: diagnosis and management”, 2012 (“the NICE Headaches Guidance”).
• NICE “Clinical Knowledge Summary for Migraine” (“the NICE Migraine CKS”), last revised August 2025.
• NICE National Guideline NG46 “Controlled drugs: safe use and management”, 2016 (“the NICE controlled drugs guidance”).
• NICE Clinical Guideline NG215 “Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults” (“the NICE dependence‑forming medicines guidance”).

6. The investigation also considered:

• The British National Formulary (“the BNF”) guidance for morphine (“the BNF Morphine Guidance”). This advises clinicians to “counsel patients and their carers on the risks of tolerance and potentially fatal unintentional overdose, as well as signs and symptoms of overdose”.
• The Health Board’s Medicines policy (2019, version 2.12). This states: “prescribers have a responsibility to monitor and ensure that the medicines they have prescribed have been reviewed.  Prescribers should refer to the patient’s existing prescriptions/supplementary charts and the patient’s available records (e.g Individual Health Record – which contains details of GP Practice and current medications – and secondary care records) before prescribing or amending a prescription…The prescriber should provide counselling for the patient about important side effects and precautions, including any need for ongoing monitoring, which if needed should be agreed between primary and secondary care clinicians.”  It also states that a pharmacist should clinically check all discharge prescriptions to ensure they are safe and appropriate.
• The All Wales Pharmacological Management of Pain Guidance (2023)
• The All-Wales Multidisciplinary medicines reconciliation policy (retired in 2025)
• The General Pharmaceutical Council “Standards for pharmacy professionals”, May 2017 (“the GPhC Standards”). These apply to pharmacy technicians and pharmacists and apply in whatever setting a patient receives care.

7. The NHS Wales Duty of Candour was introduced in Wales on 1 April 2023. The overriding principle (set out in accompanying Welsh Government Guidance) is that “being open with service users and their representatives when things go wrong in their care is the right thing to do”.  This is in addition to any professional duty of candour a healthcare professional will be subject to under their own professional practice regimes and specifically applies when a healthcare provider is responding to complaints about a service.

8. My thematic report, “Groundhog Day 2: An opportunity for cultural change in complaint handling?”, June 2023 (“the Thematic Report”). The report highlighted instances where clear evidence of service failures had not been identified by public bodies during complaint investigations, indicating a lack of openness and candour.  It also identified a recurring lack of objective review of clinical care and treatment.  It noted that NHS bodies very rarely obtain independent medical advice to assist complaint investigations.  This option is available to them under the NHS complaints procedure.

9. Mr P suffered a stroke in 2022. He was subsequently made redundant and went on to experience anxiety and depression.  He had also developed post-stroke fatigue and chronic headaches (he had previously been seen by his GP for migraine in 2010).

10. On 16 February 2024 Mr P was admitted to the Hospital with symptoms including anxiety, sweating and hallucinations. It was noted that he had suddenly stopped drinking 4 days previously after a period of 2-3 months of covertly drinking around half a bottle of vodka a day.  He was diagnosed with alcohol withdrawal and treated with detoxifying medications before being discharged on 23 February.

11. On 5 March Mrs P took Mr P to the emergency department (“the ED”) at the Hospital. He was suffering hallucinations and confusion in connection with alcohol withdrawal symptoms.  On admission the pharmacy team carried out a reconciliation of Mr P’s current medications (where a patient’s medication regime is reviewed and checked to ensure that clinicians have an accurate list of their current medications and to identify any discrepancies).  As part of this process a member of the pharmacy team contacted Mr P’s GP practice in England.

12. The medication reconciliation confirmed that at the time of the admission on 5 March Mr P was taking the following medications: warfarin, omeprazole, atorvastatin, propranolol and sertraline.  It was noted that a prescription of thiamine had been initiated in the Hospital, and that Mr P had been buying over-the-counter paracetamol.  There was no reference to Sevredol or any other opiate medication such as Zomorph (morphine sulphate in capsule form).  (Mr P’s GP records dating back to March 2021 contain no references to his having been prescribed opiate medications).

13. During the admission, Mr P was seen by alcohol liaison nurses (“ALNs”) and he received further detoxifying medication. On 7 March Mr P was transferred to the Acute Medical Unit Short Stay ward (“the AMU”) where he was under the care of a consultant nephrologist (a doctor specialising in kidney diseases and related conditions – “the Consultant”).  On 9 March a nurse recorded that Mr P had complained of a headache and he had been given paracetamol with “moderate effect”.  The following day it was noted that Mr P had reported ongoing headaches and nausea since his admission.

14. On 13 March Mr P was reviewed by an ALN. It was noted that he had completed the alcohol withdrawal regime and was feeling well with no problems reported.  He was discharged from the alcohol liaison service.  Mr P was also seen by the Consultant who noted that the aim was to discharge him the following day, after reviews by the psychiatric and physiotherapy teams.  A physiotherapy review took place later that day.

15. At around 10:15 on 14 March the Consultant saw Mr P on a ward round. He noted that Mr P was awaiting review by the psychiatric liaison team with a view to being discharged home later that day.

16. Following the ward round a prescription for morphine sulphate was added to Mr P’s medication chart. The clinical indication was recorded on the chart as “migraine” and the dose was 10mg 4 hourly PRN (pro re nata – as needed).  The chart shows that no doses were administered.  The clinical records contain no further reference to the clinical reasoning for this prescription.

17. Mr P contacted his GP practice online to request medication to help him sleep in hospital. A representative of the GP practice responded that it could not provide medication to him while he was an inpatient at the Hospital.

18. At 17:00 the psychiatric liaison nurse noted that Mr P appeared to be struggling with past grief, but he had not reported any issues with his mood or suicidal ideation and there was no evidence of any significant mental illness. It was noted that Mr P had an appointment for private counselling on 18 March which he had arranged himself.  Mr P was discharged home later that evening.  The medication list on the discharge notification included a prescription for Sevredol (10x 10mg tablets for use when required).  The medication was recorded as a pre-admission drug which was to be continued.

19. On 16 March Mr P was found unconscious at home. Mrs P called 999 and stated that she was concerned that Mr P had taken an accidental overdose of morphine.  Paramedics attended at 06:03 and attempted cardiopulmonary resuscitation, but sadly Mr P was pronounced dead shortly afterwards.  The paramedics noted that there was no evidence of any empty packets or of medication at the scene.

20. A post mortem report stated that toxicology analysis had found morphine levels in Mr P’s blood which, in a person who is not tolerant to morphine, would be consistent with fatal morphine toxicity (Mr P had 160 ng/mL of morphine in his blood – any level above 50ng/mL can be fatal). It was noted that there was no evidence of a planned suicide.  It also noted that he had previously taken Zomorph, but it was not clear where this information was obtained and no further detail was given.

21. In July a coroner’s inquest recorded a finding of death by misadventure.

22. On 8 September Mrs P submitted a formal complaint to the Health Board. On 20 September, the Health Board held a Rapid Review (“the Rapid Review” – a meeting that takes place when a concern has been raised which involves the death of a patient).  The Rapid Review was attended by the investigating officer, the Clinical Director for Medicine and Community, the Matron for Emergency Care, a Patient Safety Lead Pharmacist and a Clinical Governance Facilitator.

23. Mrs P said that after her husband suffered a stroke, he struggled enormously to manage his health. She said he suffered post stroke fatigue and struggled with sickness and with eating.  He was diagnosed with a blood condition which required daily anticoagulant (blood thinning) medication and he developed stomach ulcers, anxiety and depression.  She said that his conditions escalated, one triggering another, symptoms overlapped, and one illness could easily mask another; he underwent numerous investigations under several consultants and had numerous GP appointments and hospital attendances.  She said this constant cycle caused him significant frustration.

24. Mrs P said that, tragically, in his attempt to manage the overwhelming impact of his illnesses, her husband secretly turned to alcohol and medication as coping mechanisms. These behaviours were hidden beneath the complexity of his other conditions and were not recognised by her or by the medical professionals involved in his care.

25. Mrs P said she trusted that Mr P was in a safe environment, receiving appropriate care from professionals who were fully aware of his medical history, vulnerabilities, and the risks involved, but that trust was misplaced. She said that she had no idea that Mr P had been prescribed Sevredol on discharge from the Hospital.  She said that Mr P did not have a copy of the discharge summary on discharge, and he did not tell her about the morphine medication.

26. Mrs P said she could not understand how the Consultant could have prescribed the medication simply on the basis that Mr P asked for it, without carrying out any checks that what he was saying was reliable. She questioned whether it was appropriate to prescribe the drug given Mr P’s history of alcohol addiction, and of confusion and hallucinations.  She said it was possible his headaches were caused by the withdrawal, and that there should have been other less risky medications he could have been prescribed.  She said she feels completely failed by the very professionals she should have been able to trust: those her husband confided in and relied upon for help.

27. Mrs P said that she did not think her husband’s addiction problems were fully addressed. She felt that after being treated for withdrawal Mr P was looking for replacements for the alcohol, and that this was why he had asked the Consultant for morphine.  She said he had asked his GP for medication but had been refused.

28. Mrs P said that Mr P had not been given any guidance as to how to take morphine sulphate safely. She said she felt it was as though her husband had been sent home from hospital with a loaded gun.

29. Mrs P said she had found Mr P with an empty packet of Zomorph on the morning of 15 March, which she said was an old out of date prescription for her father she was not aware he had. She said that the only other time Mr P had been prescribed morphine was for a foot injury in 2006.  She said that when Mr P went to bed that evening, she was unaware what medication he had taken.  She said he was fully responsive and she was unaware that he was in any danger.

30. The Health Board said in response to the investigation that the Consultant had prescribed Mr P a relatively small dose of Sevredol, largely for inpatient use, based on Mr P’s explanation that he was taking it for his headaches. It said that, on that basis, the prescription was clinically appropriate.  It said that Mr P had not asked to take the medication home and if Mr P had asked for this, the Consultant would have questioned this.

31. The Health Board said that it appeared from a handwritten crib sheet completed on 8 March that the pharmacy team had confirmed Mr P’s regular medication with the GP in England by email. It said that this documentation showed that Mr P was not previously prescribed Sevredol or any other morphine preparation from his GP and he was not prescribed it by the admitting doctor.  It said the crib sheet was not printed and put on the file because it had confirmed a drug history that was already documented.  It said that a resident doctor in the Consultant’s team prepared Mr P’s discharge prescriptions with 10 x 10mg tablets of Sevredol for him to take home and noted that this was a pre-admission drug based on the information provided by Mr P.

32. The Health Board said that the interim discharge sheet provided by the Consultant’s team to the pharmacy team was a standard form which did not include a section for classifying a medication as “pre-admission drug continued” or “hospital initiated”. It said this was in line with standard practice to improve the time taken to prepare medications for discharge and to enable the doctor to prepare the discharge letter when time allows.  It said that the discharge letter was prepared on 18 March so it would likely not have been clear to the pharmacist whether the prescription was newly prescribed or restarted.  However, it said that it was not necessary to know this information to deem the prescription clinically appropriate.  It said that during the Rapid Review the Patient Safety Lead Pharmacist had advised that, even if the medication had been considered a new prescription, Mr P would still have been prescribed the same quantity of medication.

33. The Health Board provided a statement by the Consultant. In it he said that he had formed a good doctor-patient relationship with Mr P.  He said that Mr P had confided in him about a lot of his problems, and he had reassured him that he would do his best to help him.  The Consultant said that on 14 March he had finished seeing Mr P on the ward round and was about to start seeing the next patient when Mr P called him back and asked if he could have some Sevredol, that he usually took for his headaches.  He said that he had no reason to doubt Mr P as he seemed to have knowledge of the drug, given that he had asked for it by its brand name.

34. The Consultant said he had prescribed a small dose largely for inpatient use, and that the dose was not sufficient to pose a risk of addiction. He said that Mr P did not ask for some to take home and that if he had this would have raised questions and he would have been very unlikely to have prescribed it on that basis alone.  He said “I did not feel at the time, this small dose of Sevredol was an unsafe prescription.  If Mr P had asked for some “to take home”, would I have prescribed it, no I would not. If I knew he was not on it pre-admission, no, he would not have had it as I would have started with simple analgesia.  The prescription was for as and when use at a low dose in hospital.”  The Health Board said that it was regretful Mr P was given Sevredol to take home by the discharging doctor, even though the Consultant’s intention was to prescribe the medication to take as and when at a low dose in the Hospital.

35. The Health Board said that Mrs P was not informed about the prescription as Mr P did not lack mental capacity and it would not be the usual practice to routinely inform families in those circumstances. It said a copy of the discharge prescription would have been available to Mrs P to read (Mrs P said Mr P did not receive a copy).  The Health Board acknowledged that Mr P did not receive counselling about the risks of morphine based medications in accordance with the BNF Morphine Guidance.  It said this was based on the belief that Mr P had been taking the medication prior to the admission.

36. The Advisers were asked to consider whether, without the benefit of hindsight, the care or treatment had been appropriate in the situation complained about. The Ombudsman determines whether the standard of care was appropriate by making reference to relevant national standards or regulatory, professional or statutory guidance which applied at the time of the events complained about.

The Pharmacist Adviser

37. The Adviser said it was not clinically appropriate and safe for the pharmacy team to issue the Sevredol prescription to Mr P on 14 March. She said that the pharmacy team did not have enough information to make a safe supply in terms of the clinical rationale of the treatment and the pharmaceutical elements of the medicine.

38. The Adviser said that it was the pharmacy team’s responsibility to verify the clinical appropriateness of a patient’s prescribed medication. She explained that on admission the pharmacy team should within 24 hours carry out a medicines reconciliation with reference to at least 2 reliable sources of information.  The pharmacist should then review the information collected and address any problems identified before confirming that the reconciliation process was complete.  In Mr P’s case, this was confirmed on 12 March.

39. The Adviser said that the fact that the reconciliation process had not identified any reference to Sevredol having been previously prescribed should have prompted the pharmacy team to query the appropriateness of the request on 14 March. She said that the absence of any documentation of the rationale for providing a strong opioid for the treatment of migraine should also have raised a flag with the pharmacy team which should have triggered an attempt to obtain further information from the Consultant’s team.

40. The Adviser noted that there was no reference in the Hospital’s clinical records to Mr P having a history of migraine. On admission, Mr P had denied recent headaches.  She said that in her experience the use of opioids, and particularly morphine, as a single agent for the management of headaches or migraine did not follow current practice.  She said that there would be an expectation to see some history of weaker opioid use like codeine together with paracetamol.  She noted that the All Wales Pharmacological Management of Pain Guidelines state that opioid therapy should be reserved for symptoms that are persistent despite first line treatments.  In addition, she noted that the NICE Migraine CKS recommended simple analgesia (medication used to relieve pain) initially.  Further, she noted that the NICE Headaches Guidance states that opioids should not be used for the acute treatment of tension type headache, cluster headache or migraine.

41. The Adviser said that she had not seen any evidence that Mr P had previously used analgesia for headaches or migraine above and beyond the use of paracetamol he bought over-the-counter. She said that, taking this into account and that opioids are not the usual treatment for migraine or headaches, the pharmacy team should have investigated the clinical rationale for the request.  The Adviser said that this would have been the case regardless of whether Sevredol was previously prescribed or if it was being requested as a new intervention.  The Adviser noted that there were no clinically significant interactions between Sevredol and the other medications Mr P was prescribed and there was nothing in his physiology that would have increased the risk of morphine toxicity.

42. The Adviser said that it appeared that the pharmacy team had failed to carry out a number of expected checks before issuing the prescription. Firstly, she said that a pharmacist should review the medication requested on the ward and sign the pharmacist clinical check box on the medication chart.  However, the check box on the relevant chart was not signed.  She said the purpose of the review was to ensure that the prescription was clinically appropriate and should involve checking the patient notes and drug history, checking with the prescriber, and checking with the GP practice or community pharmacy.

43. The Adviser said that for this prescription the ward pharmacist would also normally check the normal treatment of chronic headaches/migraine, check the patient’s bloods and check potential interactions with other medications. As a controlled drug was involved, the check would also be expected to include steps set out in the NICE controlled drugs guidance.  These include:

• document clearly the indication and regimen for the controlled drug in the person’s care record
• discuss with the person the arrangements for reviewing and monitoring treatment
• be prepared to discuss the prescribing decision with other health professionals if further information is requested about the prescription
• check that the prescription is appropriate for the patient’s current clinical needs and to ensure that the reason for the prescription has been clearly recorded in the records.

44. The Adviser noted that, based on the medical records, the drug chart was probably completed by the Consultant’s team at around 10:15 on 14 March. The discharge prescription was entered into the pharmacy team’s prescription tracking system at 16:16.  She said there were a number of common operational reasons which could explain why the pharmacist check box remained unsigned prior to the discharge prescription being assembled.  For example, it could have been due to a lack of availability of a pharmacist to cover the ward.

45. The Adviser said that before a discharge prescription is processed and released to the patient to take home, a pharmacist is required to carry out a clinical review of the medicines. The Adviser said that the fact that the check box on the medication chart had not been signed indicated that the required checks outlined in paragraph 43 had not been carried out on the ward.  Accordingly, the pharmacist reviewing the discharge medications should have carried out these checks.

46. The Adviser said that the dose and formulation (tablets, capsule, liquid or modified release) should have been confirmed with the prescriber, the GP practice or the patient. She said that the formulation must always be stated when prescribing controlled drugs for outpatients or discharge prescriptions, but that this did not apply for prescriptions for inpatient use only.  In this case the medication chart noted the route of administration (oral) but not the form.  The Adviser noted that the 4 hourly dosage had been endorsed on the chart in green pen.  She said that she assumed that this had been done by a pharmacy technician on the basis that a pharmacist reviewing the chart would likely have signed the checkbox.

47. The Adviser explained that morphine sulphate is available as oral liquid (Oramorph liquid 10 mg / 5 ml), immediate release tablets (Sevredol 10 mg tablets) and modified release preparations (Zomorph 10 mg capsules). She said that most prescribing of morphine is done by prescribing the brand because of the safety implications of supplying a formulation with different release characteristics than what the patient is used to.  She noted that the Health Board’s Medicines policy clearly states that prescribing by brand is necessary when there are differences in bioavailability (the rate at which the active ingredient of a medication is absorbed into the bloodstream) between brands of the same medicine.  As the request was listed in the “when required” section of the medication chart with a 4 hourly dose, it would have been reasonable for the pharmacy team to assume that the prescriber intended for an immediate release formulation to be supplied.  However, the drug chart gave no indication of whether tablets or liquid should be supplied.

48. The Adviser said it was not clear how the request for morphine sulphate 10mg on the medication chart was transcribed by the pharmacy team into the issue of Sevredol tablets when the chart was not endorsed with the brand or formulation. She said that given that this information was not recorded anywhere in the clinical notes, a conversation must have taken place between the individual who compiled the discharge prescription and a member of the Consultant’s team, or Mr P, to confirm the brand.  The Adviser said that at this point, this individual within the pharmacy team should have asked for more information to provide assurance about the appropriateness of the prescription.

49. The Adviser said that the pharmacy team would also have been expected to confirm when Mr P had previously received Sevredol and if he had a supply at home. This was important to avoid the risk of patients hoarding medication, which is a safety risk and a waste of supplies.  Also, given that dispensing controlled drugs can delay discharge due to the extra checks required, it was important to check that the controlled drug was really necessary.  She said that a call to the GP practice would have been helpful, and that this should have been possible despite the fact that the information from the GP practice in England was not accessible through the Welsh Clinical Portal (an electronic patient record system used by the NHS in Wales).  She said that these checks would have revealed that Sevredol had not previously been prescribed, which would have raised questions about the appropriateness of the prescription.

50. The Adviser said that as the discharge was being prepared towards the end of the working day, there may have been pressure to process the discharge swiftly. She said that in her view it would have been safer to discharge Mr P without supplying the morphine until appropriate checks had been completed.  Paracetamol could have been supplied instead.

51. The Adviser said that both the medical team and the pharmacy team worked in isolation from each other which led to assumptions being made about Mr P and his medicines. Insufficient checks were carried out and as a result a medicine was supplied that was not safe.  She said that in the interests of service improvement the pharmacy team should reflect on Standards 2 and 5 of the GPhC Standards.

52. The Adviser explained that Standard 2 describes how pharmacy professionals must work in partnership with others as a person’s health, safety and wellbeing are dependent on these partnerships where everyone is contributing towards providing the person with the care they need. This includes other healthcare professionals and teams, carers and relatives.  The Adviser said that it would be hugely beneficial for the pharmacy team and the Consultant’s team to work together on the ward so that the expertise can be utilised from both professions to achieve an improved patient experience.  She said that a multidisciplinary approach would have been an excellent opportunity to learn about the therapeutic management of headache.

53. The Adviser noted that Standard 5 requires that pharmacy professionals must use their judgment to deliver safe and effective care. In meeting this standard, pharmacy professionals must ensure that they have the information they need to provide appropriate care.  In Mr P’s case the pharmacy team failed to take steps to obtain the information they needed to ensure the safe supply of Sevredol.

54. The Adviser said that every attempt should be made to speak to a patient about their medicines before discharge.  She noted that counselling did not take place on the assumption that Mr P was already on the medication.  However, she noted that the discharge prescription included a new medication, thiamine, and while warfarin was a pre‑admission drug, Mr P would have needed to know that the dose had not changed.  The Adviser said that the pharmacy team should have spoken Mr P to discuss these points.

55. Finally the Adviser noted that the All-Wales Multidisciplinary medicines reconciliation policy recommends that when patients are discharged from hospital the use of a Discharge Medicines Review (“DMR”) service should be considered as a method of communicating any medicines reconciliation issues for appropriate patients. She said that in primary care healthcare professionals completing medicines reconciliation must do this for all people who have been discharged from hospital or another setting.  Medicines reconciliation should happen as soon as is practically possible, before a prescription or new supply of medicines is issued and within one week of the GP practice being informed that the patient is being discharged.  However, the Adviser noted that Mr P was resident in England and while there was an equivalent Discharge Medicines Service (“DMS”) which took referrals from NHS Trusts in England, it was not clear how a health board from Wales could refer a patient.

The General Physician Adviser

56. The Adviser was asked to consider whether the medical team was acting within the range of appropriate care when prescribing morphine sulphate to Mr P. The Adviser said that it was challenging to comment on the appropriateness of the prescription given that the clinical reasoning was not documented at the time.  He said he could not find any documentation concerning the Consultant’s choice to prescribe morphine, the reasoning for the morphine prescription, his discussion with the patient, the dosage schedule for the morphine, the intended length of the prescription, or if it was intended to be continued after discharge, that is, discharge with morphine to take home.

57. The Adviser noted that the GMC Good Practice Guidance (paragraphs 69-71) emphasises the necessity for physicians to keep precise records of their activities, ensuring that there is a sufficient level of detail that includes clinical findings, investigations, and treatments provided or administered. The Adviser said that, taking this into account, the Consultant and his team did not meet the expected standard for documenting his clinical decision making.  He noted that documentation was often completed by a resident (junior) doctor whose skills in documenting a consultation were very variable, and time limitations typically prevented consultants from reviewing everything a resident doctor recorded.  Nevertheless in such time-restricted situations, it was crucial to identify the most significant elements that needed to be documented, and in this instance, that did not occur.

58. The Adviser noted that the indication given for the prescription on the medication chart was migraine and that on the same page it was recorded that Mr P was prescribed paracetamol as required, and that he had needed this on 6 occasions during the admission, including on the morning of 14 March. The Adviser said that while there was no mention in the record of the Consultant’s ward round on 14 March of Mr P complaining of pain, it was reasonable to conclude that headaches were an ongoing issue, taking into account the report on 10 March of ongoing headaches since admission.  There was no reference in the admission notes of Mr P being on morphine on admission, and no reference to a history of migraine.

59. The Adviser noted that the NICE Migraine CKS and the NICE Headaches Guidance stated that opiates should not be used for migraine or for headaches following a stroke, regardless of the cause. However, he said that in his experience, it was typical in practice, where medications had proven beneficial in the community to continue administering these in hospital.

60. The Adviser said that, if it was assumed that the Consultant understood that Mr P had been taking morphine sulphate in the community prior to the admission, and that this had provided relief, it was reasonable to prescribe this for in-patient use for the persistent headaches he had experienced during the admission. Even if the Consultant had been aware that Mr P had not been taking morphine prior to the admission, the prescription of morphine for inpatient use may have been appropriate if it was felt that the morphine was required to get on top of the pain.

61. The Adviser said that the checks the Consultant’s team carried out before arranging the prescription were not exhaustive but were appropriate on the basis that the prescription of morphine was intended for inpatient use. He said that it appeared that the Consultant did not intend to discharge Mr P with this medication.  He said that, if it had been his intention to prescribe this medication for Mr P to take home, even for a short period the Consultant would have been required to act with caution and to consider the checks and precautions set out in the GMC Prescription Guidance, the NICE controlled drugs guidance, the NICE dependence-forming medicines guidance and the BNF Morphine Guidance.  This would have included the need to counsel Mr P about the potential dangers of morphine and advise him against prolonged use of the medication.

62. The Adviser said that in these circumstances there would have been an expectation to clarify with Mr P’s GP practice if Mr P was taking morphine in the community and, even if he was, to query the wisdom of it and to suggest a plan in the discharge summary to withdraw the morphine in the community.

63. The Adviser said that the NICE dependence-forming medicines guidance recommends that before starting or continuing treatment with an opioid that all suitable management options have been discussed with and offered to the person. He noted that the guidance states that clinicians should consider whether there are any factors that might increase the person’s risk of developing problems associated with dependence, including a history of mental health problems or alcohol misuse, but cautions against withholding medications solely on the basis of one of these.  The Adviser noted that Mr P had been reviewed by the alcohol and psychiatry liaison teams.

64. The Adviser said that the GMC Prescription Guidance requires that “before proposing, prescribing or providing medications, treatment or devices, you must consider whether the information you have is sufficient and reliable enough to enable you to provide safe care”. He said that it was reasonable for the Consultant to conclude that he had enough information to make a prescription for use in hospital on the basis that Mr P had told him that he had been taking Sevredol for headaches in the community.  He said that the Consultant knew Mr P’s clinical background and was prescribing morphine at an acceptable, as required dose.

65. The Adviser said that the Consultant was not aware that the information Mr P had provided was not reliable. He said that it is usual to accept what a patient tells a clinician as being the truth unless there is good reason to believe a patient is lying.  To question the honesty of a patient without reason is time consuming and not practicable and, furthermore, compromises the trust in the doctor-patient relationship.  He said that checking the clinical records would not necessarily have indicated that Mr P’s information was unreliable, because records are not always accurate or complete.

66. The Adviser said that medicines for patients to take home are usually written up by resident doctors or pharmacists and checked by pharmacists; they are not routinely checked by consultants. He said that had the Consultant intended to issue the prescription as a new medication, this could still have been regarded as an appropriate prescription, as it was an acceptable starting dose and Mr P was only provided with 10 tablets, which at 10mg every 4 hours as required was only 2 days’ supply.  However, the difference for prescribing morphine as a new discharge medication would have been that the Consultant was required to act with caution, and in accordance with the relevant guidance as explained in paragraph 61 above.

67. The Adviser noted that the NICE dependence-forming medicines guidance (paragraph 1.2.3) advises clinicians to “during the first discussion about prescribing, give the person information and advice (in their preferred format) to help them balance the potential benefit of the medicine and other treatment options with the risk of long-term consequences”. The adviser said in this regard it would have been particularly important for Mr P to receive this information.  The provision of information to Mr P’s family was of lesser significance because Mr P was not confused.  However, if time was permitted, this would be considered a commendable practice.

68. In reaching my conclusions I have considered the advice that I have received from the Advisers, which I accept. However, the conclusions reached are my own.  I have not included every detail investigated in this report but I am satisfied that nothing of significance has been overlooked.

Whether it was clinically appropriate to prescribe Sevredol (morphine sulphate) to Mr P

69. I uphold this complaint. In the first instance, it was the responsibility of the Consultant and his team to ensure that the requested prescription was clinically appropriate.  Having regard to the General Physician Adviser’s advice, I find that the Consultant and his team failed to document a rationale for the prescription of morphine sulphate.  This was contrary to the requirements of the GMC Good Practice Guidance and the guidance documents relating to prescriptions listed in paragraphs 4, 5 and 6.  Accordingly there was a failure at the time to demonstrate that the prescription was clinically appropriate.

70. The Consultant said in later statements that the prescription was for in‑patient use and not for Mr P to take home on discharge. However, according to the note of the ward round on 14 March the plan was for Mr P to be discharged later that day, subject to a psychiatry review.  Given that the Consultant was clearly contemplating Mr P’s imminent discharge, he should have been aware of the need to clearly communicate to his team and the pharmacy team that the requested prescription was not to be given to Mr P to take home.  This intention was not recorded in the notes and it is evident that it was not communicated verbally.

71. The General Physician Adviser has explained that the prescription and dose was potentially clinically appropriate for in-patient use, and even as a new medication on discharge, regardless of whether Mr P had been taking it in the community. However, in my view it was clearly clinically inappropriate that Sevredol was issued to Mr P to take home against the Consultant’s intentions.  This could have been avoided if the rationale for the prescription had been documented and communicated to colleagues at the time.  The Health Board’s Medicines policy is clear that prescribers have a responsibility to ensure the medicines they have prescribed have  been reviewed, and that they should refer to the patient’s existing prescriptions in doing so.  Mr P’s current prescriptions may not have been visible on his electronic record because his GP practice was in England, but there is no indication that the Consultant or his team attempted to check this information.  In any event, the records from Mr P’s admission included ample information about his medications on admission.

72. The pharmacy team had an equal responsibility to verify that the prescription was appropriate and safe to issue to Mr P. The Consultant said that he would not have prescribed morphine sulphate to Mr P on 14 March if he had been aware that it was not a pre-admission prescription.  Instead, he would have started Mr P on a simple analgesia.  The pharmacy team had, by 12 March, completed a medicines reconciliation process which confirmed that morphine sulphate was not a pre-admission prescription.  I find, with reference to the Pharmacist Adviser’s advice, that there were a number of missed opportunities for the pharmacy team to query the prescription with the Consultant’s team and to make them aware of this vital information.

73. Firstly, the pharmacy team should have carried out a clinical check of the prescription on the ward; this would have involved checking the patient notes and drug history, checking with the prescriber and checking with the GP practice or the community pharmacy. It would have been particularly important to check the rationale with the prescriber given that opioids are not the usual treatment for migraine or headaches and there was no clinical justification for the prescription in the notes.  It is highly likely that even a brief conversation with the prescriber to check the rationale for the prescription would have identified that morphine sulphate was not a pre-admission medication and that the Consultant did not intend for the medication to be issued as a discharge drug.

74. It appears from the records that the medication chart was not checked by a ward pharmacist. The fact that this did not occur meant that it was especially important that the appropriate checks were carried out by the pharmacy team prior to issuing the discharge medications.  As a controlled drug had been requested, there was also an expectation to take additional steps to ensure that the prescription of Sevredol was safe (see paragraph 43).  Having regard to the Pharmacist Adviser’s advice I find that there was a failure to carry out the expected checks before issuing the prescription.

75. The pharmacy team would have been expected in the circumstances, and given that a controlled drug had been requested, to confirm that the patient had previously received Sevredol. The information given by Mr P to the Consultant that Sevredol was a pre‑admission medication was not consistent with the medication list confirmed by the reconciliation process.  This obvious discrepancy should have been flagged up during the discharge medication review and should have prompted the pharmacy team to check when the last prescription had been issued.  I agree with the Pharmacist Adviser that it should have been possible to call the GP practice or community pharmacy to confirm this.  If this was not possible due to the time of day, Mr P should have been discharged without the prescription or the discharge should have been delayed.

76. The Health Board said that the pharmacy team would not have known from the interim discharge sheet provided by the medical team whether the medication was “pre-admission drug continued” or “hospital initiated” but that it was not necessary to know this information in order to verify that the prescription was clinically appropriate.  Its Rapid Review found that even if the prescription had been categorised as a new medication, Mr P would have been supplied with the same quantity.  This ignores the fact that the Consultant did not request the medication as a new prescription and did not intend for it to be issued to Mr P on discharge: on that basis, it was clearly not clinically appropriate to issue a medication which was contrary to the intention of the prescriber.

77. While the desire to reduce the administrative burden on clinicians is understandable, Mr P’s case illustrates the significance of not requiring prescribers to indicate the status of medications (pre-admission or new) on the interim discharge sheet. If this information had been included in the interim request the pharmacy team would have been alerted to the fact that the prescription was based on the Consultant’s incorrect understanding that Mr P had been taking morphine in the community.  By the time the category had been recorded on the final discharge letter on 18 March Mr P had been discharged and had sadly died.  It seems to me that it is particularly important that the pharmacy team is aware of the intended category at the point of discharge when they are issuing controlled drugs.

78. I agree with the Pharmacist Adviser that it is likely that a member of the pharmacy team must have spoken to a member of the Consultant’s team or with Mr P to confirm the brand name and formulation for the prescription as these had not been indicated on the medication chart (this was itself a breach of the Health Board’s Medicines policy). In doing so, they missed a key opportunity to gather more information about the nature and purpose of the prescription.  At the point of discharge the pharmacy team could not have been assured that the prescription of Sevredol was safe or appropriate.  This was a significant service failure.

79. Having regard to the Pharmacist Adviser’s advice, I find that the mistaken issue of Sevredol to Mr P was the result of a failure by the medical team and the pharmacy teams to work together adequately. If appropriate multidisciplinary cooperation and communication had taken place, it is likely that the prescription would not have been issued.  Instead it was mistakenly issued to Mr P, against the prescriber’s intentions and without the benefit of a cautious and detailed consideration of the risks, as required by the relevant guidance.  It also meant that Mr P did not benefit from the advice and information that would normally be given to a patient receiving a new prescription of controlled drugs.  These were serious injustices to Mr P.

80. It is clear to me that in prescribing morphine sulphate the Consultant was strongly motivated to do as much as he could to help Mr P. He had built a good rapport with Mr P and felt he had no reason to doubt that Mr P had been prescribed Sevredol recently and had been taking it with good effect before he was admitted to hospital.  I agree that the doctor-patient relationship is built on trust and that the Consultant was entitled to believe what he was told.  However, on occasions information provided by patients will be unreliable or inaccurate.  That is why relevant guidance and standards for medical and pharmaceutical professionals emphasise the importance of appropriate documentation, communication and multidisciplinary working to reduce the risk of harm to patients arising from the use of prescribed medications, particularly in relation to controlled medications such as morphine.  It is very concerning that the systems of medication reviews in the Health Board’s pharmacy team, which should have provided a safeguard, repeatedly failed in Mr P’s case.

81. Mrs P said she felt as if her husband was handed a loaded gun. Her comments are understandable.  It was not safe to provide Mr P with Sevredol, even taking into account that it was only a 2 day supply at a relatively low dose.  In a person who was not tolerant to morphine, there was a potential risk of accidental morphine toxicity, especially where the medication was provided without appropriate advice about how to take it safely.

82. It is not known whether the morphine in Mr P’s blood at the time of his death was from the Sevredol provided by the Hospital, from an old supply of Zomorph, or a combination of both. It is not possible on the available evidence to conclude that Mr P’s overdose would not have occurred if the Sevredol had not been issued.  However, it is relevant to note that the only confirmed supply of morphine in Mr P’s possession at the time was the Sevredol issued by the Hospital.  I also note that there is no evidence that he had taken morphine prior to his admission, so it appears highly likely that he would not have been tolerant to morphine.  It is reasonable in my view to conclude that supplying Mr P with morphine sulphate in error and 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.  Taking into account the severity of these injustices, I consider that it is appropriate to recommend a significant financial redress payment to Mrs P.

Whether Mr P and his family were provided with sufficient information and support to minimise the safety risks associated with the prescription of Sevredol 

83. I uphold this complaint. In effect, the Sevredol was issued to Mr P as a new prescription, and if it had been intended as such there would, according to the BNF Morphine Guidance, have been an expectation to advise Mr P “on the risks of tolerance and potentially fatal unintentional overdose, as well as signs and symptoms of overdose”.  The Health Board acknowledged that there was a failure to counsel Mr P on these risks.  It said that this did not happen because it was thought, wrongly, that he had been taking morphine sulphate prior to admission.  As I explained above, I consider that it would only have taken basic checks by the pharmacy team or a brief conversation between the pharmacy and medical teams to reveal that this assumption was wrong.  The failure to do so led to the injustices I have described above.

84. I accept the Consultant Physician Adviser’s advice that clinicians would not have been expected to inform Mrs P about the prescription, given that Mr P was not confused at the time of discharge. I also note his advice that this would have been commendable practice.  In my view, a more considered approach to discharge planning could have involved seeking input from Mrs P, particularly given the history of concerns about substance abuse and covert consumption of alcohol.  The Health Board said that Mrs P would have been able to read the discharge summary.  This ignored the fact that the discharge summary was not completed until after Mr P’s death.

85. Very sadly, Mr P’s case illustrates the reality of the risks associated with morphine sulphate. It also underscores the importance of good communication between pharmacy and medical teams and of ensuring that processes for prescribing and reviewing medications prior to discharge are robust.  It was understandable that once Mr P had been deemed fit for discharge, there would have been an expectation for staff to work to arrange this at the earliest opportunity.  The priority, however, should always be to ensure the safety of individual patients by carrying out the necessary checks before issuing medications on discharge.  It appears that the desire to arrange a prompt discharge may have been a factor in clinicians paying insufficient attention to the safety of Mr P’s Sevredol prescription.  Given that the Health Board is likely to continue to face ongoing, and occasionally extreme, service pressures, I am concerned that there is a risk similar mistakes could be repeated.

86. It is concerning that while the Health Board has acknowledged that the prescription was issued against the intention of the prescriber, it has maintained that the prescription was appropriate. In my view the Health Board has not properly acknowledged or addressed the seriousness of the communication and process failings which led to this error.  I consider that the severity of the failings in Mr P’s case are such that they raise wider concerns about the adequacy of the Health Board’s process and practice in relation to ensuring safe prescribing on discharge.  There is clearly a potential for ongoing risk to patient safety, particularly where controlled medications are involved.  I am issuing this report as a public interest report to provide the opportunity for the Health Board to demonstrate publicly its commitment to learn lessons from Mr P’s case and to provide reassurance that the failings identified in this report will not happen again.  I also consider it is necessary to encourage wider learning from this case among prescribers and pharmacy teams in other parts of the NHS in Wales.

87. Finally, while complaint handling was not one of the heads of complaint I investigated, in light of the information that has become available during this investigation, I must address this. The NHS Wales Duty of Candour was introduced in Wales on 1 April 2023.  I consider that the Health Board’s response to Mrs P fell well short of what the duty promotes and is intended to achieve.

88. The Health Board’s complaints investigation gathered evidence that plainly showed that Mr P had been issued a controlled drug to take home against the intention of the prescribing doctor, and that this was the result of a series of failures in the medical and pharmacy teams. The fact that these failings were not identified by the Rapid Review or by the Health Board’s complaints investigation indicates that Mrs P’s complaint was not subject to a sufficiently robust or objective review.  In particular, I consider that there was a missed opportunity to obtain independent medical advice.  This would very likely have identified the failings during the Health Board’s investigation.  These complaint handling shortcomings are all the more disappointing, given that these issues were highlighted as key learning points in the Thematic Report.

89. This is the second successive public interest report I have issued involving the Health Board which has identified shortcomings in relation to the Duty of Candour. I 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.

90. I recommend that within 1 month of this report the Health Board should:

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 and Audit Committees to consider my findings and include its learning from these recommendations in its Annual Duty of Candour report.

91. I recommend that within 6 months of this report the Health Board should:

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.

92. I am pleased to note that in commenting on the draft of this report the Health Board has agreed to implement these recommendations.

Michelle Morris

Ombwdsmon Gwasanaethau Cyhoeddus | Public Services Ombudsman

5 June 2026