A patient discharged from Wrexham Maelor Hospital tragically died from a morphine overdose just two days after being mistakenly prescribed the powerful opioid. The Public Services Ombudsman for Wales highlighted a 'series of failures' by hospital staff, describing the incident as an 'extremely serious injustice'.
The man, identified only as Mr P, had been admitted to the hospital in March 2024 for treatment related to alcohol withdrawal symptoms. While an inpatient, he was given Sevredol, a morphine sulphate medication used for severe pain. However, upon his discharge, a doctor incorrectly prescribed him the opioid to take home, under the mistaken belief he had been using it prior to his admission. The Ombudsman's report found that subsequent checks by both medical and pharmacy teams, which should have identified and rectified this critical error, were not carried out effectively.
Mr P died on 16 March, two days after leaving the hospital, with a coroner concluding his death was a result of misadventure. His widow expressed profound distress, stating she felt her husband had been sent home 'with a loaded gun'. The Ombudsman's investigation noted that official opioid guidance mandates patients should be advised on the 'risks of tolerance and potentially fatal unintentional overdose', advice which was not provided to Mr P. While the report could not definitively state the hospital's medication directly caused his death, it concluded that 'supplying morphine sulphate in error, without appropriate advice, significantly increased the risk of accidental overdose'.
Michelle Morris, Public Services Ombudsman for Wales, emphasised the gravity of the situation, stating, 'This represents an extremely serious injustice to Mr P and to his family.' She added that the identified failings should have been addressed much earlier. As a result of the findings, the Ombudsman has recommended an apology to Mrs P and a payment of £2,000 to acknowledge the injustice. Furthermore, a comprehensive review of practices within Betsi Cadwaladr University Health Board's medical and pharmacy teams is to be conducted within the next six months.
Chris Lynes, Deputy Executive Director of Nursing at Betsi Cadwaladr University Health Board, issued an apology, admitting the board 'fell short of the standard that should be expected'. He affirmed their commitment to ensuring the lessons learned are fully implemented and that a direct letter of apology would be sent to Mr P's family. Mr Lynes also addressed concerns regarding the handling of Mrs P's complaint, stating the health board is dedicated to the Duty of Candour, which obligates them to be open and honest with the public.