Man mistakenly prescribed morphine died two days later from overdose
A man died of a morphine overdose two days after he was mistakenly prescribed morphine while being discharged from hospital, the Public Services Ombudsman for Wales said.
The Ombudsman blamed “a series of failings” by staff at Wrexham Maelor Hospital and described what happened as “an extremely serious injustice”.
The man’s widow said she felt as if her husband had been sent home from the hospital “with a loaded gun”.
Betsi Cadwaladr medical board apologized and admitted it “fell short”.
The patient, identified only as Mr. P, was hospitalized in March 2024 for treatment of alcohol withdrawal symptoms.
While in the hospital, he was given the morphine sulfate drug Sevredol, a type of opioid used to treat severe pain.
However, he was later mistakenly prescribed some medications to take home by the discharged doctor, who believed he had taken them prior to hospitalization.
The report found there was a “series of failures by medical and pharmacy teams to carry out expected checks”, which “could have identified this error”.
Mr P died of a morphine overdose on 16 March, two days after leaving hospital.
The coroner concluded that his death was the result of misfortune.
Mr P was discharged from Wrexham Maelor Hospital and died two days later [BBC]
The Ombudsman found that, in accordance with official opioid guidance, Mr P should have been advised of the “risks of tolerance and potentially fatal unintentional overdose”.
Mr P’s widow said she “felt completely failed by the professionals she was supposed to trust”.
Although it was not possible to say whether the medication taken from hospital directly caused death, the ombudsman found that “accidental administration of morphine sulphate without appropriate advice significantly increased the risk of accidental overdose”.
‘We fell short’
Michelle Morris, Public Services Ombudsman for Wales, said: “This represents an extremely serious injustice towards Mr P and his family.”
He added: “These failures should have been identified and addressed at an earlier stage.”
Her report recommends an apology to Mrs P and a payment of £2,000 to reflect the injustices caused.
He also said a full review of practices across the board’s medical and pharmacy teams should be carried out within the next six months.
Chris Lynes, assistant executive director of Nursing at Betsi Cadwaladr University Health Board, said: “We fell short of the standard that should have been expected. We are sending a letter of apology directly to Mr P’s family shortly.”
“We are committed to ensuring that the identified lessons are fully implemented,” he added.
He also addressed the ombudsman’s concerns about the way Ms P’s complaint was handled, saying: “The medical board is fully committed to the Duty of Candour, our contract with the public to be open and honest, and we will continue to address the concerns raised in the ombudsman’s conclusion.”
