A man from Wrexham died from a morphine overdose just two days after being wrongly prescribed the opioid painkiller following discharge from Wrexham Maelor Hospital in March 2024, the Public Services Ombudsman for Wales has found. The investigation revealed serious failings in hospital prescribing and dispensing processes that contributed to the fatal mistake.
Fatal Prescribing Error
The patient, admitted for alcohol withdrawal treatment, was prescribed Sevredol (morphine sulphate) during his stay. However, a discharging doctor erroneously believed the man was already on the drug before admission and authorised it for home use. This error was compounded by multiple failures in medical and pharmacy checks.
Grieving Family Responds
The deceased’s widow described the discharge as sending her husband home “with a loaded gun,” expressing deep sorrow and feeling betrayed by the healthcare system. The coroner recorded the death as misadventure, while the Ombudsman confirmed the incorrect morphine supply greatly raised the risk of accidental overdose.
Ombudsman Demands Reforms
Michelle Morris, Public Services Ombudsman for Wales, condemned the case as an “extremely serious injustice.” She has called on Betsi Cadwaladr University Health Board to formally apologise and provide a £2,000 payment to the family. The report also demands a full review of prescribing and pharmacy procedures within six months to avoid future tragedies.
Health Board Issues Apology
Chris Lynes, deputy executive director of Nursing at Betsi Cadwaladr University Health Board, admitted the board “fell short of the standard expected.” He confirmed a direct apology to the family and pledged to implement the lessons learned, reinforcing the organisation’s commitment to transparency under the Duty of Candour.
