Princess Alexandra Hospital apologises after patient’s morphine overdose death
Health / Thu 20th Nov 2025 at 01:51pm
A 63-year-old cancer patient died after he was prescribed too much morphine in hospital.
Paulino Amico’s death was hastened and contributed to by multiple morphine overdoses between June 10 and 11, 2024, due to a prescription error that was not scrutinised, Essex coroner Sonia Hayes has ruled.
Mr Amico received six doses of Morphine Sulfate tablets in less than 24 hours instead of two.
Mr Amico had metastatic bladder cancer that had not responded to treatment.
He was discharged from hospital on May 29, 2024 and was oxygen dependent.
He developed severe bilateral pneumonia and was admitted into Princess Alexandra Hospital on June 9 2024, and treated with antibiotics, nebulisers and fluids.
He was not seen in person by a doctor who altered his prescription in the emergency department on June 10.
On the afternoon of June 10, Mr Amico’s medication chart was not scrutinised when he had a medical review, as he was deteriorating.
Due to a prescription error, Mr Amico received multiple overdoses of a controlled drug, morphine sulphate (slow release), on June 10 and 11, 2024, resulting in morphine accumulation that was partially reversed with naloxone, which reverses an opioid overdose, on June 11.
Mr Amico was not deemed suitable for admission to intensive care for Naloxone infusion.
Mr Amico’s morphine overdose was partially treated – there was an immediate response to Naloxone, but the opioid reversal for overdose was not in accordance with British National Formulary guidelines or with an NHS England alert previously issued.
He died on June 12, 2024, at Princess Alexandra Hospital.
A statement from Ms Hayes said: “Mr Amico’s death from metastatic bladder cancer was hastened and contributed to by multiple morphine overdoses between June 10 and 11, 2024, due to a prescription error that was not scrutinised.
“Morphine reversal and subsequent pain relief were not managed according to the guidelines, and Mr Amico suffered acute withdrawal syndrome.”
Jo Ward, Interim Chief Nurse, said: “We have written to Mr Amico’s loved ones to offer our deepest condolences and apologies.
“Our review of his tragic death immediately highlighted errors in his treatment. We have immediately implemented a number of changes to prevent a recurrence.
“Among our actions, we have altered our electronic systems so that it is no longer possible to inaccurately prescribe morphine in this way. We have eagerly accepted the suggestion by our senior nurses, which the coroner mentioned, to introduce mandatory medicines administration refresher training for nurses.
“We are committed to not only learning from this incident but taking strong action. We welcome the coroner’s comments and suggestions and will be issuing a full response to the coroner on actions taken.”
Seamus
2025-11-20 15:56:49
The usual "We are very sorry. We have already changed procedures and we will learn from this" Whilst not a single Doctor, Nurse, Specialist or Ward Manager faces any action whatso ever. Where is the accountability if there is no consequence?
Mazzy
2025-11-20 18:30:26
What use is an apology?
Adam
2025-11-20 19:04:58
Standard things the state says when something goes wrong, lessons learned etc. It never is as organs of the state just ultimately do not care about you or your life. Jail the people involved and make the NHS pension scheme pay for any compensation which should be at least 7 figures.
Brian Ashton
2025-11-20 19:43:12
If i make a mistake while driving and injured someone. Is it acceptable in court to say sorry, my heart fel apologies to the victim, I have made changed to my driving and it won't happen again. Of course not. But when this keeps happening again and again. Is this response actually enough
Jesse
2025-11-20 21:05:40
There should be a governmental committee investigating this hospital. We should absolutely demand this because it has become a risk. We are paying for this service out of our hard work and taxes. It’s clear new management isn’t making any real changes. There are so many incidents reported, the hospital rankings are extremely poor, and there should be accountability. I’ve only used the A&E department once and I will avoid going there. I genuinely fear that place and it was not lack of staff I saw or lack of equipment, I saw incompetence and in too many instances that it became worrying. There needs to be an audit of staff asap and drastic measures taken, this is not a job for mediocrity
Roger Lee
2025-11-20 21:27:08
I can't imagine what it is like when you are charged with the care of someone who is dying from any illness, let alone cancer. The pressure of wanting to eliminate their pain and suffering, whilst trying to follow complex procedures, must be challenging at the best of times. Stats for 2021 -2022 state that PAH admitted 57,349 patients, treated 28,031 A&E attendances and delivered 2,500 babies. I have been taking my wife to the cancer unit at PAH since the beginning of the year and have to say that the whole team there have been really efficient, caring, attentive and focused on ridding her of this dreadful illness. My condolences to Mr Amico's family but please let's not persecute our wonderful and dedicated NHS staff here. We are all human and none of us are truly infallible.
Tracy Smith
2025-11-20 22:07:02
This hospital and the wards need investigating by the cqc as a matter of urgency,too many errors,not enough communication when your a patient or your families, horrendous. The only thing good about PAH is the Williams Day Unit !!!!!!
SH
2025-11-20 22:29:07
It's horrifying that no one caught onto the morphine being prescribed 6 times a day or at least didn't question it if they did catch it. I don't know what electronic system they use at PAH but as someone working at a different NHS trust, our system has aggressive warnings that if we attempted to prescribe morphine 6 times a day, the pharmacists would also be on our case. PAH has been deteriorating over the years and needs to start afresh for it to be fit for patients, they've wasted so much money over the years that could've gone into improving the service and I have acquaintances who have personally been affected by PAH's care, some life-long. I work in a tertiary centre so we get referrals from DGH's like PAH and it's really sad when we see how affected patients are by this sort of care by the time they reach us, many through years and hundreds of appointments later for them to finally be referred on where sometimes it's too late as they've been turned away and let down by the system, some of which were noted to be "hypochondriacs".
Daz
2025-11-21 00:47:49
PAH failed my mother. After two weeks of cancelled scans and missed symptoms, she died of a ruptured spleen on a Monday morning, following a weekend with zero medical presence. Because we had the money to fight, we forced an inquest. The hospital responded with teams of lawyers and executives, spending hundreds of thousands to grind us down and keep us out of court. They know the system: they hold the records and they game the settlement offers to ensure the truth stays buried. We settled for £350,000 plus costs, but only after signing a gagging order. Stories like ours rarely see the light of day; we were paid to keep quiet.
Philip Steel
2025-11-21 00:59:00
Roger - They not only gave him an overdose - They then forced a dying man to go cold turkey - Absolutely horrific and inhumane
Mark
2025-11-21 07:55:13
Roger Lee very wisely said,I agree with you
Lucy
2025-11-21 09:00:58
PAH Harlow ranks 118th out of 121 trusts for cancer waiting times. Being in the bottom 3% of a failing system is unacceptable. My partner was put on a waiting list for a scan after getting nowhere with the GP. He went to PAH A&E twice; first, he was dismissed with painkillers, and later told it was likely Scheuermann's disease. The very next day, UCLH A&E scanned him immediately, found a lesion, and admitted him. Within weeks, he was diagnosed with Stage IV cancer and began treatment. Two months after treatment finished, we received a letter from Harlow asking, ‘Do you still want your scan?’ It’s a disgraceful place and the people of Harlow deserve better.
David Forman
2025-11-21 09:12:08
I am considering having tattooed on my chest 'Dear ambulance worker, please do not take me PAH, I prefer Lister Hospital'. The senior management at PAH need to be cleared out. However, patients can do something about this. You have patient choice when you need elective surgery. Just choose somewhere other than PAH. See NHS Choices at https://www.nhs.uk/using-the-nhs/about-the-nhs/your-choices-in-the-nhs/#:~:text=Did%20you%20know%20that%20in,the%20NHS%20e%2DReferral%20service.
David Forman
2025-11-21 09:43:55
The Coroner's Prevention of Future Deaths report lists 8 Matters of Concern. The first includes medical device not maintained. Quote: "(1) The consultant required a discharge plan for oxygen therapy to be in place before Mr Amico could go home. The hospital discharge plan and medications were confusing and the referral for oxygen therapy requirement was unclear, and the PAT testing for the machine was out of date. Paramedics advised the family that the oxygen provided on Mr Amico’s discharge was low flow and was not meeting his oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew equipment." Out of date PAT testing in a hospital setting that, had it been done, would have detected low flow! See Coroner's report at https://www.judiciary.uk/prevention-of-future-death-reports/paolino-amico-prevention-of-future-deaths-report/
Guy Flegman
2025-11-21 12:26:37
The NHS has become a lottery at every level and people are leaving the country because of it. If you are rich you still have to rely on the NHS in an emergency, and if the care is a lottery then you will move somewhere where you can pay for private emergency health care or to somewhere where they have a system that works. Also PAT testing would not show the fault described above as it only tests for electrical safety thus showing even the coroners office is not working correctly
Anna
2025-11-24 13:35:22
Princess Alexandra Hospital, a legacy of failure and broken Promises 9 years ago, I made a formal complaint to Princess Alexandra Hospital regarding a serious error that had devastating consequences. I sat in a room with senior staff, listened to their apologies, and was reassured that lessons would be learned and improvements would be implemented. I was told that change was coming, and that patient safety would be taken seriously. Nearly a decade later, I am horrified to see that nothing meaningful has changed. The same dangerous patterns are happening again and again. Patients are still being ignored. Families are still kept uninformed. Communication is still chaotic or non-existent. Staff attitudes remain dismissive, defensive, and at times outright hostile. This hospital continues to make serious, avoidable mistakes, mistakes that cause suffering, fear, and lasting harm. And each time, families are expected to simply accept it. The culture of Princess Alexandra Hospital is one of silence, arrogance, and denial. They push forward as though nothing is wrong, while real people endure unnecessary pain and distress under their care. The emotional toll this place inflicts on families cannot be overstated. Promises were made. Commitments were made. And nothing has changed. To witness the same failures repeated again and again is beyond disappointing, it is unacceptable. Patients deserve safety. Families deserve transparency. Staff owe basic respect. This hospital has had years to improve, and yet the failures persist. The consequences are real, and they are severe. It is long past time for accountability and urgent, transformative change. The public deserves far better than what this hospital delivers.
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