Wrexham: Man died of overdose after mistaken morphine prescription

A man identified only as Mr P passed away from a morphine overdose two days after being mistakenly prescribed the drug upon discharge from Wrexham Maelor Hospital, according to the Public Services Ombudsman for Wales. The investigation revealed multiple failures by hospital staff that contributed to the tragic outcome, which the ombudsman described as an “extremely serious injustice.”

Mr P had been admitted in March 2024 for treatment related to alcohol withdrawal and was administered Sevredol, a morphine sulphate opioid aimed at alleviating severe pain. However, upon discharge, a doctor erroneously prescribed him morphine to take home, mistakenly believing he had been using the medication prior to admission. The report highlighted a breakdown in the usual checks performed by both medical and pharmacy teams, which failed to catch this error. Consequently, Mr P died from an overdose on 16 March, two days after leaving hospital. A coroner later ruled his death as a misadventure.

The ombudsman’s report stressed that Mr P had not been properly warned about the risks associated with opioid use, including tolerance and the danger of unintentional overdose. While it could not be definitively determined whether the dispensed medication directly caused his death, the provision of morphine without appropriate advice was found to have significantly raised the risk of accidental overdose. Mr P’s widow expressed her profound sense of betrayal, stating she felt completely failed by the professionals she had trusted.

In response, Betsi Cadwaladr University Health Board acknowledged shortcomings in their procedures. Chris Lynes, the board’s deputy executive director of nursing, stated: “We fell short of the standard that should be expected. We are sending a direct letter of apology to Mr P’s family imminently.” He further emphasized the board’s commitment to learning from the incident and improving practices as outlined in the ombudsman’s recommendations, which include a formal apology, a payment of £2,000 to Mrs P, and a thorough review of medical and pharmacy protocols within six months. Michelle Morris, Public Services Ombudsman for Wales, commented: “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.

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