Disabling decision-support alerts on a hospital prescribing system may have contributed to a patient\u2019s death by paracetamol overdose, NHS England has suggested.<\/p>\n
Paula Doreen Hughes, aged 55 years, died on 10 January 2022 following a medication error, which resulted in an unintended therapeutic excess of\u00a0paracetamol, Liliane Field, assistant coroner for Inner South London, concluded in a prevention of future deaths report (PFD) published on 19 December 2025.<\/a><\/p>\n In responses to the PFD, both NHS England and the Royal Pharmaceutical Society (RPS) said that even if prescribing system alerts are enabled, they should not replace clinicians\u2019 professional responsibility.<\/p>\n The PFD was sent to Lewisham and Greenwich NHS Trust, NHS England, the RPS, IT system supplier Oracle and Cerner, the Medicines and Healthcare Products Regulatory Agency and the Royal College of Physicians \u2014 all of whom have a legal requirement to respond.<\/p>\n Hughes was admitted to Queen Elizabeth Hospital, Woolwich, London, following a fall and was prescribed both co-codamol and later paracetamol during her stay.<\/p>\n In the PFD, the coroner wrote: \u201cPharmacy review failed to\u00a0pick up the concurrent prescription and both drugs were administered\u00a0together on three or four occasions until the duplicate prescription was deleted\u00a0at around 14:30 on 8 January [2022].<\/p>\n \u201cThe two prescribing doctors failed to recognise that Mrs Hughes was already prescribed a paracetamol-containing drug. Two nurses failed to recognise\u00a0they were administering two paracetamol-containing drugs. A pharmacist\u00a0failed to identify the concurrent prescriptions during reconciliation.\u201d<\/p>\n However, the coroner said that Lewisham and Greenwich NHS Trust\u2018s response to the incident had been \u201cswift and commendable\u201d, including introducing measures within the electronic prescribing system \u201cwhich eliminated concurrent prescriptions of paracetamol-containing drugs\u201d and \u201csignificantly reduced therapeutic excesses of\u00a0paracetamol based on weight\u201d.<\/p>\n In its response to the PFD<\/a>, published on 5 December 2025, NHS England noted that electronic prescribing systems can alert clinicians if more than one paracetamol-containing drug is prescribed concurrently. However, in this case, \u201cit is assumed that it was not \u2018switched on\u2019\u201d, it said.<\/p>\n \u201cHad this feature been enabled, there is a reasonable likelihood that the error would have been prevented.\u201d<\/p>\n NHS England added: \u201cWhile these alerts are an important safety feature, they are designed to support, not replace, clinical judgement and responsibility. In particular, there is a risk that frequent alerts can lead to \u2018alert fatigue\u2019 and desensitisation, increasing the risk of overlooking critical warnings.<\/p>\n \u201cThis reinforces the need for careful consideration of which alerts remain active, even for common contraindications, as repeated exposure can normalise risk and condition users not to pay attention to alerts.\u201d<\/p>\n NHS England said therapeutic duplication was included as a theme within its 2025 release of its \u2018ePrescribing Risk and Safety Evaluation\u2019 (ePRaSE) self-assessment toolkit, which is intended to test how effectively e-prescribing systems respond to high-risk prescribing scenarios.<\/p>\n It also said it would consider this incident as part of the review of the scenarios for the next release in 2026 as a priority area.<\/p>\n In its response<\/a> to the PFD, published on 9 December 2025, IT system supplier Oracle and Cerner said the functionality to display alert notifications to protect against paracetamol overdosing was available within its system; however, it was up to NHS trusts to decide whether or how to enable these features.<\/p>\n In its response<\/a> to the coroner\u2019s report, published on 1 December 2025, the RPS said: \u201cWe believe that steps could be taken to try and build alerts and warnings for the unacceptable duplication of medicines into these electronic prescribing systems to make them safer. This would require national oversight to coordinate work with secondary care system suppliers.\u201d<\/p>\n \u201cThere were opportunities for healthcare professionals (without the need for any digital intervention) to identify the medication error. Electronic prescribing and medicines administration systems and clinical decision support tools have been widely adopted in healthcare settings to support clinicians in making prescribing decisions and reduce the number of prescribing errors. They, however, do not replace the personal responsibility and accountability for prescribing and clinical decision-making for healthcare professionals.\u201d<\/p>\n A spokesperson for Lewisham and Greenwich NHS Trust said: \u201cWe continue to offer our deep condolences to Paula Hughes\u2019s family and loved ones. As a trust, we note the findings from the PFD and have issued a thorough and considered response, which is available here<\/a>.<\/p>\n \u201cThis includes the steps that we are committed to taking to ensure that this doesn\u2019t happen again.\u201d<\/p><\/p>\n","protected":false},"excerpt":{"rendered":"Disabling decision-support alerts on a hospital prescribing system may have contributed to a patient\u2019s death by paracetamol overdose,…\n","protected":false},"author":2,"featured_media":393018,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[33],"tags":[49,48,84,377],"class_list":{"0":"post-393017","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-medication","8":"tag-ca","9":"tag-canada","10":"tag-health","11":"tag-medication"},"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/posts\/393017","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/comments?post=393017"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/posts\/393017\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/media\/393018"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/media?parent=393017"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/categories?post=393017"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/tags?post=393017"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}