There was poor communication and a lack of checks before the medicine was given to the man
A patient was wrongly given morphine when discharged from hospital and died of an overdose two days later. The patient was given the drug without being made aware of the risks or given guidance on using it safely.
An inquiry by the ombudsman has said it was a “serious injustice” that the patient was prescribed Sevredol.
The patient, who is not being named, was treated at Wrexham Maelor Hospital, which is part of Betsi Cadwaladr University Health Board. His wife made the complaint about the care of her late husband in March 2024.
The Public Services Ombudsman for Wales said a series of failures in medication prescribing and checking, and poor communication between medical and pharmacy teams, led to the mistake.
The patient, referred to as 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.
“The 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,” the ombudsman says. For our free daily briefing on the biggest issues facing the nation, sign up to the Wales Matters newsletter here
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, and the patient shouldn’t have been given it, the report found.
He died of a morphine overdose two 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,” the ombudsman’s release says.
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.”
The ombudsman criticised the health board for not being open with the family in the aftermath.
Health boards are subject to the “duty of candour”, which is a legal and professional obligation to be completely open, honest, and transparent with patients or their families when something goes wrong during treatment that has caused, or could cause, significant harm
“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 said.
The report was issued so the health board, and others, are aware, the ombudsman said.
She has suggested an apology and financial redress is paid, that a review should be carried out, and learning points issued to staff.
Deputy executive director of nursing at Betsi Cadwaladr University Health Board, Chris Lynes, said: “On behalf of the health board I apologise unreservedly for the failures identified in Mr P’s care. We fell short of the standard that should be expected.
“We are sending a direct letter of apology to his family imminently and we wish to assure them that we take the ombudsman’s findings very seriously and we are committed to ensuring the lessons identified are fully acted upon.
““We also acknowledge her comments surrounding our complaint handling and responses.
“The health board is fully committed to the duty of candour, the contract we have with the public to be open and honest, and we will continue to address the concerns raised in the ombudsman’s conclusion.”



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