Wrexham Maelor Hospital Error: Patient Dies From Morphine Overdose After Discharge
A patient, identified as Mr P, died on 16 March, two days after being discharged from Wrexham Maelor Hospital. The cause of death was a morphine overdose, according to the Public Services Ombudsman for Wales. Mr P had been hospitalised in March 2024 for alcohol withdrawal and was mistakenly prescribed the opioid Sevredol to take home by a discharging doctor who believed it was pre-existing medication.
The Ombudsman's report cited a "series of failures by the medical and pharmacy teams to carry out expected checks" that would have identified the prescribing error. Mr P's widow stated she felt her husband was sent home "with a loaded gun." The report also noted that official opioid guidance requiring advice on "risks of tolerance and potentially fatal unintentional overdose" was not followed.
While the Ombudsman could not definitively attribute the death solely to the hospital-supplied medication, 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, characterised the situation as an "extremely serious injustice."
Betsi Cadwaladr University Health Board acknowledged it "fell short of the standard that should be expected" and committed to implementing the Ombudsman's recommendations. These include a £2,000 payment to Mrs P and a comprehensive review of medical and pharmacy practices within six months to ensure lessons are acted upon.
