Ombudsman finds BCUHB failings after patient given morphine in error and died two days later
The Public Services Ombudsman for Wales has issued a public interest report finding that Betsi Cadwaladr University Health Board issued a patient with morphine sulphate in error on discharge from Wrexham Maelor Hospital, and that he died of a morphine overdose two days later.
The Ombudsman investigated after the man’s wife, referred to in the report as Mrs P, complained about care provided to her late husband at the hospital in March 2024.
The investigation found that the prescribing consultant had intended the morphine sulphate, marketed as Sevredol, for use in hospital only, and had wrongly believed the patient had been taking it before admission.
A series of failures by the medical and pharmacy teams to carry out expected checks meant the error was not identified before the patient left hospital.
The report also found that there was no appropriate clinical reason documented for the prescription, given that opioids are not recommended for migraine or headache treatment under relevant guidance.
The man, referred to as Mr P, was given a controlled drug without being told of the risks or given guidance on safe use, including the risk of potentially fatal unintentional overdose.
The Ombudsman found it was not safe to have provided Mr P with Sevredol in those circumstances.
Mr P died of a morphine overdose two days after leaving hospital. The Ombudsman’s report said it was not possible to determine whether the hospital supply directly caused his death, but that supplying morphine sulphate in error, without appropriate advice, significantly increased the risk of accidental overdose.
The Ombudsman described the outcome as an extremely serious injustice to Mr P and his family.
Michelle Morris, Public Services Ombudsman for Wales, 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.”
“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 Duty of Candour is a legal requirement on NHS bodies in Wales to be open and honest with patients and their families when things go wrong.
Ms Morris said she was issuing the report as a public interest report so that the health board would publicly demonstrate how it had learned from the failings, what action it was taking, and to provide reassurance that similar failings would not happen in future.
She said it was also important that lessons were learned more widely across NHS Wales, and that other health boards reviewed their own arrangements.
Betsi Cadwaladr University Health Board accepted all of the Ombudsman’s recommendations.
These included apologising to Mrs P and making a financial redress payment to her, sharing learning with all medical and pharmacy staff, and carrying out a full review of processes and practices within the medical and pharmacy teams.
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.”
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