A patient was incorrectly given morphine upon leaving hospital and died of an overdose two days later, an investigation has revealed. The individual was discharged without being informed of the risks or provided with safe usage guidance.
Ombudsman Highlights 'Serious Injustice'
The Public Services Ombudsman for Wales deemed the prescribing of Sevredol to the patient a 'serious injustice'. The patient, referred to as Mr P, was treated at Wrexham Maelor Hospital, part of Betsi Cadwaladr University Health Board. His wife lodged a complaint in March 2024.
The ombudsman identified a chain of failures in medication prescribing and checking, along with poor communication between medical and pharmacy teams, leading to the error. The prescribing consultant had intended the morphine sulphate for hospital use only, mistakenly believing Mr P had taken it before admission.
Expected checks that would have caught the mistake were not performed by medical or pharmacy staff. The ombudsman stated: '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.'
Additionally, there was no documentation of appropriate clinical reasons for the prescription, given that opioids are not recommended for migraine or headache treatment under relevant guidelines. Mr P was given a controlled drug without awareness of risks or safe-use guidance, including the potential for fatal unintentional overdose.
He died of a morphine overdose two days after discharge. The ombudsman noted: '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.'
Health Board Criticised for Lack of Candour
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 also criticised the health board for not being open with the family afterwards, falling short of the 'duty of candour' – a legal obligation to be transparent when something goes wrong that causes significant harm. Morris expects the health board to fully embed this duty in everyday practice.
The report was issued to raise awareness across health boards. She has recommended an apology, financial redress, a review, and learning points for staff.
Chris Lynes, deputy executive director of nursing at Betsi Cadwaladr University Health Board, 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.'
