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Disabling decision-support alerts on a hospital prescribing system may have contributed to a patient’s death by paracetamol overdose, NHS England has suggested.
Paula Doreen Hughes, aged 55 years, died on 10 January 2022 following a medication error, which resulted in an unintended therapeutic excess of paracetamol, Liliane Field, assistant coroner for Inner South London, concluded in a prevention of future deaths report (PFD) published on 19 December 2025.
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’ professional responsibility.
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 — all of whom have a legal requirement to respond.
Hughes was admitted to Queen Elizabeth Hospital, Woolwich, London, following a fall and was prescribed both co-codamol and later paracetamol during her stay.
In the PFD, the coroner wrote: “Pharmacy review failed to pick up the concurrent prescription and both drugs were administered together on three or four occasions until the duplicate prescription was deleted at around 14:30 on 8 January [2022].
“The two prescribing doctors failed to recognise that Mrs Hughes was already prescribed a paracetamol-containing drug. Two nurses failed to recognise they were administering two paracetamol-containing drugs. A pharmacist failed to identify the concurrent prescriptions during reconciliation.”
However, the coroner said that Lewisham and Greenwich NHS Trust‘s response to the incident had been “swift and commendable”, including introducing measures within the electronic prescribing system “which eliminated concurrent prescriptions of paracetamol-containing drugs” and “significantly reduced therapeutic excesses of paracetamol based on weight”.
In its response to the PFD, 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, “it is assumed that it was not ‘switched on’”, it said.
“Had this feature been enabled, there is a reasonable likelihood that the error would have been prevented.”
NHS England added: “While 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 ‘alert fatigue’ and desensitisation, increasing the risk of overlooking critical warnings.
“This 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.”
NHS England said therapeutic duplication was included as a theme within its 2025 release of its ‘ePrescribing Risk and Safety Evaluation’ (ePRaSE) self-assessment toolkit, which is intended to test how effectively e-prescribing systems respond to high-risk prescribing scenarios.
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.
In its response 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.
In its response to the coroner’s report, published on 1 December 2025, the RPS said: “We 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.”
“There 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.”
A spokesperson for Lewisham and Greenwich NHS Trust said: “We continue to offer our deep condolences to Paula Hughes’s 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.
“This includes the steps that we are committed to taking to ensure that this doesn’t happen again.”
