Paolino Amico

Sonia Hayes 
HM Area Coroner for Essex 
Essex and Thurrock Coroner’s Service 
Essex County Council 
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

20th January 2026  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Paolino Amico who died 
on 12 June 2024.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  17 
November 2025 concerning the death of Paolino Amico on 12 June 2024. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my  deep  condolences  to  Paolino’s  family and  loved  ones.  NHS  England  is  keen  to 
assure  the  family  and  yourself  that  the  concerns  raised  about  Paolino’s  care  have 
been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any anguish this delay may have caused to Paolino’s family or friends. I realise that 
responses to Coroners’ Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones, and I appreciate 
this will have been an incredibly difficult time for them. 

Your  Report  raises  concerns  around  morphine  administration  involving  multiple 
nurses,  who  had  all  completed  their  original  training  outside  of  the  UK  and  had 
undertaken  a  Trust’s  medicines  administration  training.  Such  training  should  have 
enabled the nurses to recognise that the prescription of morphine sulphate (MST) was 
inappropriate,  and  that  there  had  been  a  prescription  error  leading  to  multiple 
overdoses of MST. You also raised that medicines administration refresher training for 
nurses is not mandatory. 

Inaccurate or incomplete recording of medication in the patient’s records  

Nurses, as key members of the healthcare team, play a vital role in the administration, 
monitoring and documentation of medication. It is difficult to ascertain from this specific 
case  and  the  information  available  what  specific  systems  and  other  contributory 
factors  may  have  hindered  the  nurse  in  the  Emergency  Department  (ED)  from 
documenting or scrutinising the administration of MST, noting the fast paced and busy 
ED environment.  

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 Evidence and published research highlights that distractions and interruptions cause 
memory  lapses  and  task  omissions,  and  are  recognised  factors  leading  to  nurses 
forgetting 
to  omissions  of  care. 
Documentation  is  guided  by  the  rights  of  medication  administration  and  regulatory 
standards  set  by  bodies  like  the  Nursing  and  Midwifery  Council  (NMC)  and  Care 
Quality Commission (CQC).   

to  document  care  and  potentially 

leading 

Contemporaneous  patient  medical  records  must  be  completed  at  the  time  of 
administration  to  avoid  errors,  and  the  practitioner  administering  the  medication  is 
accountable  for  their  actions.  To  ensure  high  standards  of  care,  the  NMC  has 
established comprehensive guidelines and standards for medicines management.  

Inappropriate escalation to the junior doctor for prescribing pain relief  

Your Report raises concerns around the ED nurse approaching a foundation year 1 
doctor to prescribe pain relief, rather than escalating to the nurse in charge or a senior 
doctor.  Evidence  and  published  literature  recognises  that  human  factors  such  as 
workload, fatigue and competing priorities can contribute to errors in clinical practice; 
therefore supporting our workforce in these and other settings is essential to improving 
patient safety.  

Year 1 foundation doctors can prescribe medication, under supervision. It may be that 
the nurse was not aware of this and assumed that the doctor would have asked a more 
senior doctor to check and sign off on the medication prescription.  

Medication error and scrutinising the prescription 

Your Report also raises concerns around the prescription error and lack of scrutiny, 
despite multiple nurses being involved in checking and administering a controlled drug. 
Administering medicines is a high risk task in healthcare and medication checks are 
critical  to  prevent  errors  (defined  as  any  mistake  in  the  prescribing,  dispensing, 
administering or monitoring of medicines).  

Annually,  an  estimated  237  million  medication  errors  occur  with  administration  and 
prescribing  being  the  most  common.  Of  this  66  million  are  potentially  clinically 
significant  errors..  In  line  with  the  National  Patient  Safety  strategy,  healthcare 
providers must be committed to minimising risk and harm to patients and, to ensure 
safety,  the  NHS  is  using  a  Just  and  Learning  Culture  approach  which  involves 
identifying the causes of errors and learning from them.  

Registered  nurses  are  expected  to  scrutinise  prescriptions,  ensuring  that  they  are 
legible,  valid  and  appropriate  for  the  patient  before  administration.  This  includes 
checking the patient’s identity, the medicine name, dose, route and timing as well as 
confirming  that  the  prescription  complies  with  legal  requirements,  particularly  for 
controlled drugs. However, as stated above, based on the information available it is 
difficult to ascertain what system factors may have contributed to the medication errors 
in Paolino’s case.  

Controlled  drugs  must  be  administered  in  strict  accordance  with  policy,  usually 
requiring  a  second  registered  nurse  to  witness  preparation and administration,  with 

 
 
 
 
 
 
 
 
 
 both signatures recorded in the controlled drugs register. National Institute for Health 
and  Care  Excellence  (NICE)  medicines  optimisation  guidance  (NG  5,  2015) 
emphasises the need for robust systems to verify prescriptions and prevent avoidable 
harm. When multiple nurses check a controlled drug but fail to identify an error, this 
highlights a breakdown in the safety system such as clinical oversight of prescribing 
by  pharmacists.  The  Royal  College  of  Emergency  Medicines  and  UK  Clinical 
Pharmacy  Association  have  issued  a  joint  statement  on  the  benefits  of  pharmacy 
support to emergency departments. 

NHS England offers support to providers to improve the safe use of controlled drugs. 
NHS Trusts must appoint a Controlled Drugs Accountable Officer and a Medication 
Safety Officer. Their remits differ however both have a duty to ensure the safe use of 
opioids  in  their  organisations.  NHS  England  operates  networks  for  both  groups  to 
receive  and  spread  the  learning  from  errors.  We  also  offer  guidance  and  tools  to 
enable NHS Trusts to effectively learn from patient safety incidents through the Patient 
Safety  Incident  Response  Framework.  We  note  that  the  Patient  Safety  Incident 
Response Plan for the Princess Alexandra Hospital includes workstreams to improve 
safety in ED, in Medicines management, controlled drugs and medicines reconciliation 

Failure to escalate National Early Warning Score (NEWS)  

When  a  patient’s  NEWS  score  reaches  10,  this  represents  a  critical  level  of 
physiological deterioration requiring an urgent medical response. Providers will have 
local  policies  and  Standard  Operating  Procedures  (SOP)  in  place  for  the  safe  and 
effective management of this. This information would be important to ensure lessons 
are learnt and the risks of reoccurrence are mitigated.  

NEWS  was  developed  by  the  Royal  College  of  Physicians  in  2012,  aimed  at 
standardising  the  process  for  recording,  scoring  and  responding  to  changes  in 
routinely measured physiological parameters in acutely unwell patients, and to support 
the reliable recognition and response to acute deterioration. The guidance is clear that 
scores as high as 10 mandate an immediate urgent call to a senior doctor or the rapid 
response  team.  Registered  nurses  are  professionally  accountable  under  the  NMC 
Code to ‘Raise concerns immediately if you believe a person is at risk.’ It is recognised 
that  a  failure  to  escalate  promptly  in  these  circumstances  places  the  patient  at 
significant risk of harm.  

Documentation must also reflect the NEWS score, the actions taken and the time of 
escalation, ensuring transparency and accountability.  

Overdosing medication 

It is disappointing that, despite multiple nurses checking and administering a controlled 
drug on 5 separate occasions between 10 and 11 June 2024, it did not raise concerns 
about the potential for a prescription error, nor was it noted that Paolino had already 
received  1  dose  of  MST  that  morning.  As  above,  when  multiple  nurses  check  a 
controlled drug but fail to identify an error, this highlights a breakdown in the safety 
system such as a lack of an independent double checking process. Registered nurses 
are  expected  to  exercise  vigilance  when  scrutinising  prescriptions  and  preparing 
medicines, ensuring that doses are correct and appropriate for the patient. The NMC 

 
 
 
 
 
 
 
 Code  requires  nurses  to  ‘preserve  safety’  and  ‘practise  effectively’,  which  includes 
preventing  harm  through  careful  checking  and  adherence  to  local  medicines 
management policies.  

Lack of mandatory refresher training  

Registered nurses are expected to maintain up-to-date knowledge and competence in 
medicines management through initial training and regular refresher programmes. The 
NMC  Code  requires  nurses  to  ‘keep  your  knowledge  and  skills  up  to  date’  and  to 
practise safely by recognising the limits of their competence.  

The  NICE  medicines  optimisation  guidance  NG  5  (2015)  referenced  above 
recommends that organisations support healthcare professionals through training and 
education to ensure safe prescribing, dispensing and administration. In this specific 
case,  education  and  training  alone  would  not  prevent  these  types  of  safety  system 
issues  and  would  not  be  sufficient  to  mitigate  the  risk  of  reoccurrence.  Systems 
improvements and mechanisms will need to be implemented to ensure lessons are 
learnt  and  that  the  current  organisational  and  systems  factors  and  processes 
highlighted in this case are addressed, to ensure the safe and effective checking and 
administration  of  medications.  This  has  been  substantiated  by  safety  research  and 
incident analysis.  

The  Royal  College  of  Nursing  guidance  emphasises  that  medicines  administration 
training should be refreshed periodically to ensure familiarity with current legislation, 
local policies and best practice in areas such as controlled drugs, high risk medicines, 
and  safe  prescribing.  Refresher  training  also  reinforces  the  importance  of  double 
checking, accurate documentation and escalation procedures when errors or adverse 
reactions occur.  

Local Actions 

The Princess Alexandra Hospital NHS Trust will be providing their own response to 
this Report, however, the Hertfordshire & West Essex ICB have advised NHS England 
of  the  Trust’s  governance  arrangements  and  actions  being  taken  to  address  the 
concerns  raised.  It  is  understood  that  the  Trust’s  Patient  Safety  Group  (PSG)  has 
active oversight of several of the areas highlighted in the Report, particularly medicines 
safety, recognition of deterioration, and incident learning. 

Medicines safety is a standing agenda item at their PSG, supported by the Medicines 
Optimisation Group and Medication Safety Officer, with regular review of prescribing 
and administration incidents, controlled drugs governance, and training compliance. 
The PSG has recognised gaps in training uptake and has been sighted on system-
level  behaviours  through  its  routine  oversight  of  medicines  safety  and  incident 
learning. Themes PSG have been sighted on include: 

•  Variable  engagement  with  medicines  safety  processes,  such  as  inconsistent 
uptake  of  medicines  management  training  and  variation  in  adherence  to 
medicines administration standards. 

 
 
 
 
 
 • 

Inconsistent escalation behaviours, for example delays in escalating concerns 
or delays in closing incidents and embedding learning. 

•  Operational  pressures  influencing  practice,  such  as  missed  opportunities  to 

scrutinise prescriptions or incomplete discharge processes. 

•  Variation  in  response  to  clinical  or  governance  challenge,  where  concerns 
about documentation or compliance have not always been acted on promptly. 

PSG has strengthened leadership challenge, required divisional action plans where 
compliance  is  low,  and  continues  to  monitor  medicines  safety,  controlled  drugs 
governance and deterioration as standing agenda items.” 

Recognition  and  escalation  of  deteriorating  patients  is  overseen  through  the 
Deteriorating  Patient  Group,  with  additional  mitigation  introduced  via  12-hour  harm 
reviews  in  urgent  care  settings  to  examine  escalation,  observations  and  clinical 
response. 

The PSG has also strengthened its focus on timely incident closure and learning, with 
senior  leadership  challenges  and  actions  in  place  to  ensure  serious  incidents  are 
reviewed,  learning  is  embedded,  and  assurance  is  provided  through  the  Quality  & 
Safety Committee and Trust Board. 

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 
Paolino, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director  
NHS England

Hamstel Road 
Harlow 
Essex 
CM20 1QX 

8th January 2026 

Private and Confidential 

Area Coroner Sonia Hayes 
Essex Coroner’s Court 
Chelmsford County Hall 
Victoria Road 
Chelmsford 
CM1 1QH 

Dear Coroner Hayes, 

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS  

I write in the matter of the late Paolino Amico in response to your recent Regulation 
28 Report to prevent future deaths which was issued on 17th November 2025. 

Mr Amico was admitted to Princess Alexandra Hospital on 14th May 2024 
complaining of shortness of breath and productive cough. He had a medical history 
of metastatic urothelial carcinoma and had received experimental treatment at Barts 
Hospital however this had been discontinued due to disease progression. CT scan 
on admission identified dramatic progression of pulmonary metastatic disease since 
a previous CT scan in January 2024. There was no pulmonary embolism. 

He was treated with oxygen, nebulisers, fluids and antibiotics. His oxygen 
requirements during admission were 2 litres reducing to 1litre. 

Following discussion with the family a Do not resuscitate form was signed. A 
discussion was had with the family regarding any further treatment such as 
chemotherapy. The oncology consultant advised the family that Mr Amico was 
unable to have chemotherapy whilst on oxygen. It was discussed that attempts to 
wean Mr Amico off oxygen would be attempted.  

Mr Amico was discharged home on 29th May 2024 with referral to the community 
palliative care and home oxygen. Unfortunately, he was readmitted to Princess 
Alexandra Hospital on 9th June 2024 with community acquired pneumonia and died 
on 12th June 2024. 

 
 
 
  
 
 
 
 
 
 
 
      
 
 
 
 
 
 
 I note the eight areas of concern which you have raised and will respond to in turn. 

1.  The consultant required a discharge plan for oxygen therapy to be in 

place before Mr Amico could go home.  

The hospital discharge plan and medications were confusing and the 
referral for oxygen therapy requirement was unclear 

PAT testing for the machine was out of date.  

Paramedics advised the family that the oxygen provided on Mr Amico’s 
discharge was low flow and was not meeting his oxygen requirements 
with his oxygen saturations at 68% and this immediately improved on 
ambulance crew equipment.  

On the 28th May 2024 Mr Amico was assessed by the respiratory Clinical nurse 
specialist with Mr Amico’s daughter and the following plan was agreed. He was 
assessed as requiring home oxygen, nebulisers, analgesia and review of the 
dietician when at home. At the time of assessment Mr Amico was requiring 1litre of 
oxygen per min via nasal cannula. His oxygen saturation level was 89% 

The respiratory clinical nurse specialist completed an order form for home oxygen 
requesting the following: 

•  2 static concentrators to provide 1litre of oxygen per min via a nasal cannula 

for 20-22 hours per day. 

•  4 Standard ambulatory cylinders to provide 1litre of oxygen per min via nasal 

cannula for 1-4 hours a day 

The equipment was delivered and installed to Mr Amico’s home address on 29th May 
2024 by BOC gases the company who supply home oxygen, prior to his discharge. 

Portable Appliance Testing (PAT) is a process used to ensure the safety of electrical 
appliances and equipment. The head of patient services at BOC has informed our 
operations team that they do not PAT test concentrators as there is no legal 
requirement for them to be PAT tested. 

Our operations team report that the concentrator had likely been PAT tested when it 
had been previously provided to a care home as part of their legal requirements. 

BOC have confirmed that they will ensure any stickers are removed from any 
concentrators being returned prior to leasing them out again and apologise for any 
confusion. 

The discharge plan included a referral to the community respiratory team to monitor 
oxygen, district nursing for medication review and Specialist palliative care team 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (SPCT) and to Isabel Hospice. Referral was completed on the 29th May 
2024. 

The comments from the paramedics relate to Mr Amico’s oxygen requirement at the 
time they assessed him. At the time of discharge the respiratory nurse had assessed 
Mr Amico and his oxygen requirements based on an evidence-based assessment 
and the appropriate level of oxygen based on those observations was prescribed 
and arranged for him at home. 

2.  Mr Amico did not receive his prescribed medications during his second 

admissions when he was readmitted to hospital on 9 June. 

a.  On 9 June a doctor in Accident & Emergency had reviewed Mr Amico’s 

prescribed medications and increased liquid oral morphine sulphate 10 mg 
in 5mL Solution 4 hourly as required with 2.5 -5 mg max 6 doses at 22:57 
hours with slow released morphine sulphate (MST) continued 2 times daily. 
Trust staff did not administer any morphine to Mr Amico although he and 
his family were raising concerns about his high level of pain. 

Mr Amico was admitted to PAHT on 9th June 2024 at 17.21and he was triaged by 
advanced clinical practitioner (ACP) at 18.26. At 18.50 he was reviewed by a FY2 
doctor and referred to the medical team.  

He was reviewed by the medical clinician at 21.33 and no account was taken that he 
had not received his 8pm MST dose. 

On 9th June 2024 at 22.58 Morphine Sulphate (MST) modified release was 
prescribed for twice daily at 08.00 and 20.00. Oramorph was also prescribed as 
required (PRN). 

b.  The family was informed incorrectly that medications had not been 

prescribed. On the morning of 10 June, the family were given 
permission by a nurse to dispense from Mr Amico’s own supply of 
medications that he had brought to the hospital due to his level of 
pain. This was not accurately recorded in Mr Amico’s record. Mr 
Amico took his prescribed morning dose of MST. 

On 9th June 2024 at 22.58 Morphine Sulphate (MST) modified release was 
prescribed for Mr Amico twice daily at 08.00 and 20.00. Oramorph was also 
prescribed PRN. 

The emergency department do not have a stock of MST. At the time there was not a 
patients’ own controlled drug book to record controlled medication. The 
administration was recorded on JAC, the Trust electronic medication system that his 
family had given his regular prescribed medication.  

As part of the learning from this incident a patients’ own controlled drug book has 
now been introduced in ED to ensure that this is recorded and accounted for within 

the department. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 c.  On 10 June the nurse in the emergency department did not escalate 

to the nurse in charge or a senior doctor that she could not locate the 
doctor allocated to Mr Amico and instead approached a foundation 
year 1 doctor to prescribe pain relief for Mr Amico. The nurse asked 
the doctor who was junior and very busy that the frequency of the 
morphine needed to be increased for Mr Amico. The doctor did not 
escalate the matter and did not review Mr Amico before prescribing a 
controlled drug. 

A Multi-Disciplinary After-Action Review meeting was held, including staff involved in 
the incident. This identified learnings and actions to be taken. It established that the 
ED nurses looking after Mr Amico had been redeployed from another ward so were 
not fully aware of the ED escalation process that occurs in the emergency 
department.  

As part of the learning following the after action review the escalation process with 
nurses redeployed from base ward to other areas need to be included as part of the 
orientation specific to the area they are redeployed to.  

Further learning was discussed in regards to doctors: regardless of seniority, they 
must take responsibility when approached by nurses to review a patient. If they 
acknowledge the patient is not under their care and a nurse is unable to locate the 
appropriate doctor, they must escalate to the nurse in charge (NIC). Once a doctor 
has agreed to review a patient they should review the relevant background and 
assess the patient face to face. 

The doctor who changed the prescription reviewed the incident with his educational 
supervisor and as part of his reflection acknowledged that he would take the 
responsibility to not alter any the treatment without at least reviewing the patient first.  

d.  Neither the nurse nor the doctor sufficiently scrutinised the 

medication prescribed on 9th June on the Trust system that would 
have shown the correct medications. This led to a prescription error 
being made with MST being increased from 2 times daily to 4 times 
daily. Mr Amico was not referred for pain management. 

Mr Amico’s regular MST was modified to 4 hourly. Modifying an existing prescription 
bypasses the medication clinical support (MCDS) attached to EPMA (Electronic 
Prescribing & Medications Administration system), as well as any warnings or 
additional information. We have now removed the modify option to prescriptions (this 
was done first on our previous EPMA system, and has continued onto 
Cerner/AlexHealth).  

What this means is that to change a prescription, a doctor would have to either click 
‘cancel/reorder’ or ‘discontinue’ the drug and add a new drug to the system, both of 
which would force the prescriber into acknowledging any warnings and overriding 
any interactions picked up by the MCDS.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 In addition, we have recognised there is a huge variation in morphine 
formulation and type and have made the naming of products clearer. For example, 
MST is noted as ‘Morphine MODIFIED RELEASE 12 HOURLY tablets on the 
system. We have also pre-defined the frequency as twice a day. 

If the same prescription was to be changed today, it would bring up warnings about 
formulations of opioids, have the frequency predefined as twice a day, and the 
MCDS would flag to the prescriber that morphine sulphate oral solution is already 
prescribed. 

This brings in an additional layer of clinical review and judgement, guiding the 
prescriber to select an appropriate medication. For all modified-release preparations 
of morphine, this list labels them as ’12 hourly preparations’ and pre-loads the 
frequency as twice a day.  

e.  Mr Amico then moved to a ward. Multiple nurses were involved in 
checking and administering a controlled drug morphine sulphate 
slow release (MST) on 5 separate occasions between 10 and 11 June 
2024 and did not raise concerns about the potential for a prescription 
error or note that Mr Amico had already received 1 dose of MST that 
morning. 

The Trust acknowledged that the medication administration error occurred and this 
was discussed with the staff involved through the following actions: 

An after action review meeting took place on 26th June 2024 and included:  

•  Associate Director for Governance and Quality – Chair  
•  Doctor involved in prescribing the MST  
•  Acute Medicine Clinical Lead (to support doctor involved)  
•  Nurses involved in administration  
•  Matron for Medicine Division (to support nurses involved)  
•  Lead Professional Nurse Advocate  
•  Medication Safety Officer  
•  Patient Safety & Quality Leads – Medicine and Urgent & Emergency Care 

Restorative clinical supervision took place in June 2024, which was a reflective 
discussion with special emphasis on how to manage challenging prescribers and 
how to have an effective professional discussion when in doubt of management plan, 
and how to escalate higher if still in doubt.  

Ward Practice development team carried out a professional nurse advocate session, 
completed in June 2024. This included a review of controlled drugs and their 
frequencies, palliative care and controlled drug frequency changes, importance of 
clear communication and escalation when patient's Early Warning Score changes.  

Monthly ongoing meetings with ward matron and chief pharmacist and EPMA lead to 
review all incident themes for ongoing monitoring. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Learning was shared across the Divisions and Trustwide by the Patient 
Safety and Quality (PSQ) Lead Nurse and discussed at Medicine Divisional 
Governance meeting and learning from deaths group.  

3.  Mr Amico’s NEWS score increased, and an emergency call was not put 

out on 11 June when it was established that Mr Amico was 
unresponsive even to pain from 03:00 hours. 

The Trust acknowledges there are discrepancies with the medical records 
documentation around the period of the 11th June. 

From the observation records and medication chart, Mr Amico’s NEWS score at 
01.47 was 3, at 05.25 MST was given to Mr Amico which consists of an oral tablet 
being given and swallowed.  

At 06.46 Mr Amico’s NEWS score increased to 10. This was escalated to hospital 
@night, CCOT and Nurse in charge. It was at this time the family raised concerns 
regards to the MST being given 4 hourly instead of Oramorph  

It is noted that the documentation from the doctor who reviewed Mr Amico suggests 
that Mr Amico had been unresponsive since 3 am however the Trust is unable to 
ascertain where this information came from as the observation and medication 
records do not corroborate that finding. 

There were no concerns raised around 03.00 am that Mr Amico was unresponsive or 
that his condition had deteriorated at that time. If that had been the case then his 
deteriorating condition would have been escalated to the OOH team.  

If there had been any concerns around him being unresponsive at 05.25 when he 
took the further dose of MST, escalation would have occurred at that time. 

4.  The on-call doctor was called approximately one hour after Mr Amico’s 
NEWS score was found to be 10 and arrived at 07:50, this was not an 
emergency call. The on-call doctor had not been informed of: 

a.  the deterioration in Mr Amico’s presentation during the night 

The hospital at night team were contacted following the raised NEWS score of 10 at 
06.46 and attended immediately. The doctor was told by the family that Mr Amico 
had been unresponsive since 3am, however medication had been taken by Mr 
Amico at 05.25. 

Blood gas recording was at 07.30. 

b.  that the family had informed nursing staff of their concerns Mr Amico 

had been given the wrong medication when he was noted to be 
unresponsive at approximately 03:00 hours, that should have 
immediately raised concerns about an overdose of MST. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 According to the nursing records it was at 06.46 when Mr Amico was found 
to be drowsier when his relative asked what medication he was being given through 
the night and questioned why he had been receiving MST every 4 hours as he only 
took it twice in 24hours at home. 

5.  The on-call doctor escalated concerns immediately but no emergency 

call was put out. 

An emergency call was not required at that time as all appropriate care was initiated 
promptly. 

6.  Mr Amico morphine overdose was partially treated: 

a.  There was an immediate response to Naloxone but the opioid reversal 
for overdose was not in accordance with British National Formulary 
guidelines or with an NHS England alert previously issued. 

The prescription of Naloxone was incorrect; it was prescribed in line with acute 
overdoses and not for patients on long-acting chronic therapy. There is prescribing 
guidance in the BNF, and in the prescribing alert (first released in 2014, and 
rereleased in 2019). Appendix 1 

The BNF highlights that doses used in acute opioid/opiate overdose may NOT be 
appropriate for the management of opioid/opiate induced respiratory depression and 
sedation in those receiving palliative care and in chronic opioid/opiate use. The 
recommended dose for adults in post-operative respiratory depression and for 
palliative care and chronic opioid/opiate use by intravenous injection is 100 to 200 
micrograms (1.5 to 3 micrograms/kg). If the response is inadequate, give subsequent 
dose of 100 micrograms every two minutes. Even where doses are given as 
recommended, there is still a need for careful monitoring of vital observations and 
maintaining or restoring pain relief.  

This has been shared by the palliative care team at educational events. The 
Medication Safety Officer is also liaising with the EPMA team to see how we can 
utilise AlexHealth to inform prescribers/safeguard against a repeat.  

We have also had two ICS/PAH collaborative events around opioids for grand round 
(one in November 2024, another booked for February 2026).  

The Trust also has a policy on Naloxone, which was reviewed following this incident. 
see Appendix 2. 

b. There was no consideration or plan for alternative pain management in a 

patient who had been receiving morphine pain relief as part of his 
treatment plan for cancer. 

c.  Mr Amico suffered acute withdrawal syndrome and family complained 

about his suffering to hospital staff that they stated was not ameliorated. 
An emergency call would have triggered the attendance of an 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Anaesthetist who could have given advice on opioid reversal in 
a palliative patient. 

It is documented in the hospital records that Mr Amico was reviewed by a palliative 
care consultant on 11th June 2024 at 10.10am and a plan was discussed with the 
family regarding starting midazolam for agitation and alfentanil via a syringe driver 
for pain. 

On 11th June 2024 at 13.00 Mr Amico was reviewed by an CT3 anaesthetist and the 
plan regarding the Naloxone infusion was discussed with the ITU consultant who 
agreed the plan. On 12th June at 03.00 Mr Amico seemed agitated and haloperidol 
1mg was given followed by a further dose. Agitation subsided. 
Mr Amico was prescribed S/C morphine (2.5mg every 4 hours if needed) after the 
MST, but none was administered.  

7.  Multiple nurses were involved in morphine administration, and all had 

completed their original training outside of the UK and had undertaken a 
Trust medicines administration training that should have recognised   
the prescription of MST 4 times a day was not appropriate. Mr Amico 
received 6 doses of MST in less than 24 hours instead of 2. 

All nurses involved in this case were internationally trained and, upon joining the 
Trust, undertook medicines administration training in line with NMC standards. This 
training is currently designated as essential within PAHT, meaning it is compulsory 
for staff in roles requiring it. Responsibility for completion lies with the individual and 
their line manager, and compliance is monitored through the Trust’s TiMS system 
and appraisals. 

The medicines administration training includes key topics such as general medicines 
management, insulin administration, antimicrobial resistance, and controlled drugs. It 
is intended to ensure safe prescribing and administration practices. Despite this, the 
error occurred, resulting in Mr Amico receiving six doses of MST within 24 hours 
instead of the prescribed two. This indicates a failure in the application of training 
and highlights the need for strengthened competency assurance. 

The Trust is reviewing this incident under its governance processes and considering 
additional measures, including enhanced training and monitoring, to prevent 
recurrence. 

8.  Medicines administration refresher training for nurses is not mandatory 

and the Trust in reviewing this case has not followed a local 
recommendation from senior nurses for this to be included. 

Medicines administration refresher training is currently not mandatory at PAHT. 

Initial training is classified as essential, but refresher 

 
 
 
 
 
 
 
 
 
 courses are not systematically required or monitored. Senior nursing staff 
previously recommended that refresher training be included as part of 
ongoing competency assurance; however, this recommendation has not yet been 
implemented. 

The Mandatory Learning Oversight Group (MLOG) is actively reviewing the training 
framework, including whether medicines management training should move from 
essential to mandatory status. If adopted, this would ensure refresher training is 
tracked, monitored, and reported at governance level. The Trust acknowledges this 
gap and is considering changes to strengthen compliance and patient safety. 
Mandatory training is defined by NHS England as statutory (legal requirement) and 
NHS mandatory (NHS Core Skills Framework).  This is still the responsibility of the 
individual and line manager to complete but is monitored and reported via PAHT 
governance and NHSE. 

In 2023 PAHT confirmed Medical Gases training could be mandatory.  Currently 
2216 staff including 630 staff in Medical and Dental staff group have Medical Gases 
on their profiles as Mandatory training.   

I hope this letter helps address the concerns raised in your Regulation 28 notice for 
prevention of future deaths. 

Please do not hesitate to contact me if you require any further details. 

 Yours sincerely 

Chief Medical Officer