A coroner’s investigation has determined that a prescribing error caused the death of an infant in 2025. The mistake involved an incorrect dosage of a drug frequently administered in neonatal care.
This ruling has renewed scrutiny over medication safety in pediatric wards, where high-risk prescriptions are part of daily practice.
Professional pharmacy organizations have since advocated for tighter supervision of electronic prescribing platforms, which the coroner’s report criticized for being underutilized in this incident. The Royal Pharmaceutical Society (RPS) argued that pharmacists should take a more active role in validating high-risk prescriptions, especially in neonatal units.
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The case comes after a string of widely publicized prescribing mistakes in 2024 and 2025, including a fatal morphine overdose in a pediatric oncology department. While the majority of errors are intercepted before administration, the coroner stressed that overconfidence in low-risk settings can lead to devastating consequences. The report cited staff fatigue as a contributing element.
Healthcare providers are now evaluating their protocols for automated alerts within electronic health records, though adoption rates differ significantly across institutions. Some systems only trigger warnings after a prescription is submitted, while others demand manual confirmation at multiple stages.