“During the course of the hearing it became apparent that staff on the ward (whether…”

The coroner’s concerns

– (1) During the course of the hearing it became apparent that staff on the ward (whether doctor or nurse) were not familiar with either the national morphine guidelines (BNF) or indeed those of the hospital. The Court is concerned that such lack of awareness may not be limited to that ward or that hospital. (2) It was concerning that even the hospital’s own Serious Incident report had incorrectly quoted the hospital’s guidelines as to the safe dose of IV morphine and that neither the investigatory team or any of the clinical staff who subsequently read that report had picked up on this. (3) I am concerned as to the adequacy of education re safe morphine doses that newly qualified doctors and locum doctors receive, and how this is audited. 4) I am concerned that the hospital’s own guidelines regarding morphine administration for acute pain management have not been revised since 2013 and are at odds with the current BNF guidelines (in terms of appropriate doses and patient vulnerability). 5) I was concerned that this incident arose as a result of a doctor and a nurse failing to understanding each other, and the nurse subsequently feeling that she had no choice but to administer an IV dose that she believed to be dangerous, and in particular that: a) The drug charts design did not facilitate clear instructions for titration for one-off doses of IV morphine. b) The nurse did not feel confident enough to challenge the prescription (as she perceived it) effectively or escalate / refer to another doctor.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2020-0186

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0