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Hospital Error Leads to Fatal Morphine Overdose
20 Jun
Summary
- Man died from morphine overdose two days after discharge.
- Hospital staff failures led to incorrect prescription.
- Health board apologised for falling short of expected standards.
A man, identified as Mr P, died of a morphine overdose in March 2026, two days after being mistakenly prescribed the opioid upon his discharge from Wrexham Maelor Hospital. The Public Services Ombudsman for Wales has attributed the tragedy to a series of failures by hospital staff and pharmacy teams who did not conduct the necessary checks.
Mr P had been admitted for alcohol withdrawal symptoms and was receiving morphine sulphate for severe pain. The discharging doctor mistakenly believed he had been taking the medication prior to admission, leading to the incorrect take-home prescription. This error, coupled with a lack of essential advice on opioid risks, significantly increased the chance of an accidental overdose, according to the ombudsman's report.
The Betsi Cadwaladr University Health Board has since apologized for falling short of expected standards and is imminently sending a letter of apology to the patient's widow. The health board is also committed to reviewing its practices and ensuring lessons are learned.
The ombudsman's report recommended a £2,000 payment to the widow and a comprehensive review of medical and pharmacy team practices within six months.
