Hospital failures linked to patient’s fatal overdose, Ombudsman finds

Mark Mansfield

A series of failures by hospital doctors and pharmacists led to a patient being wrongly supplied with morphine when he was discharged from hospital, before he died from a fatal overdose two days later, a watchdog has found.

A highly critical public interest report by the Public Services Ombudsman for Wales found that staff at Wrexham Maelor Hospital failed to carry out basic checks that would have revealed the medication had been prescribed in error.

The investigation concluded that the patient, referred to as Mr P, was discharged with morphine sulphate despite the prescribing consultant intending it to be used only while he was in hospital. The error went unnoticed because of failures in prescribing, checking procedures and communication between medical and pharmacy teams.

Mr P died from a morphine overdose two days after leaving hospital.

While the Ombudsman said it was not possible to determine whether the medication supplied by the hospital directly caused his death, it found that issuing the drug without proper advice or guidance significantly increased the risk of an accidental overdose.

The complaint was brought by Mr P’s widow, Mrs P, following his treatment at Wrexham Maelor Hospital in March 2024.

The report found that the consultant prescribed morphine sulphate after mistakenly believing Mr P had already been taking the drug before he was admitted to hospital. In reality, a medicines reconciliation carried out during his admission had confirmed that he had not previously been prescribed morphine or any other opioid medication.

The Ombudsman found that both medical and pharmacy staff missed multiple opportunities to identify the mistake.

The prescribing consultant later told investigators that he intended the medication only for use in hospital and would not have prescribed it for Mr P to take home if he had known it was not already part of his treatment regime.

However, that intention was not properly documented or communicated to colleagues, and the medication was included on Mr P’s discharge prescription.

The report found that pharmacists failed to carry out expected checks before supplying the drug and did not challenge obvious discrepancies between the discharge prescription and information already gathered about Mr P’s medication history.

Investigators also found that opioids such as morphine are not recommended treatments for migraine or headaches under national guidance, yet there was no documented clinical rationale explaining why the medication had been prescribed.

No warnings

A further concern was that neither Mr P nor his family were given appropriate information about the risks associated with morphine.

The Ombudsman found that he was supplied with a controlled drug without being warned about the possibility of a potentially fatal overdose or given guidance on how to use it safely.

Mrs P told investigators she had no idea her husband had been prescribed morphine when he returned home from hospital.

She said she felt her husband had effectively been handed “a loaded gun”.

The Ombudsman described the consequences as “an extremely serious injustice” to both Mr P and his family.

In 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.”

Ms Morris also criticised Betsi Cadwaladr University Health Board’s handling of the subsequent complaint, saying it had failed to properly acknowledge the seriousness of what had happened.

She said: “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.”

The Ombudsman noted that this was the second successive public interest report involving the health board to identify shortcomings in relation to the Duty of Candour.

Recommendations

Betsi Cadwaladr University Health Board has accepted a series of recommendations arising from the investigation.

They include issuing a formal apology to Mrs P, making a £2,000 financial redress payment, sharing lessons from the case with medical and pharmacy staff, and carrying out a comprehensive review of prescribing and discharge procedures.

The review will also examine communication between medical and pharmacy teams, whether discharge paperwork should more clearly identify newly prescribed medication, and difficulties clinicians face when accessing prescription information from GP practices in England.

The health board has also been instructed to conduct an audit of discharge prescriptions from the Acute Medical Unit and produce an action plan to address any further shortcomings identified.

The Ombudsman said she had decided to publish the findings in the public interest to ensure lessons are learned both within Betsi Cadwaladr University Health Board and more widely across NHS Wales.