We’ve launched a national investigation looking at medicine omissions in learning disability secure units.

Medication omission has long been recognised through research as one of the most common medication risks. It can lead to avoidable harm, increased length of hospital stays, and complications around treatment-based decision making.

Reference event

The parent of an adult service user with learning disabilities notified HSIB that her son was regularly not being offered prescribed medication.

He was an inpatient in a secure unit for people with learning disabilities in a mental health hospital. She believed the staff prioritised medication for mental health conditions and were less concerned about him taking medication for his physical health.

Find out more about the reference event in our interim bulletin.

Investigation summary

The following safety issues have been identified and form the basis of this investigation:

  • Weakness in the systems involved in the prescribing and administration of medication, including medicines optimisation, self-administration, and escalation procedures.
  • ‘Parity of esteem’ between physical and mental health medications. Parity of esteem means valuing physical health equally with mental health.

The investigation is looking at the factors which influence prescribing and administration of medicines in mental health hospitals, to reduce omissions.

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