Relevant Serious Case Reviews

A search of the NSPCC’s catalogue of Serious Case reviews found 32 cases of child death or serious injury between 2003 and 2015 where prescription or over the counter medication was an issue. A sample summary of these cases can be found below and highlight the importance of pharmacy staff being alert to issues of abuse and neglect;

Katie; Report reflecting on how services and agencies responded to a case of fabricated induced illness (FII). Case concerned a mother who repeatedly took her child to health services from age 4-months to 3-years reporting seizures, fitting and vomiting. Fabricated or Induced Illness was suspected and a care order granted. Identifies issues including: over-reliance on parental reports; repeat prescriptions and increases in medication without witnessing symptoms;

Child H: Serious incident involving a 21-month-old boy, who was admitted to hospital in September 2013, after ingesting 40-50mls of opiate-based medication. Mother pleaded guilty to charges associated with her care of Child H and received a custodial sentence. Mother had been known to children’s services since she was 15-years-old. Mother was known to be using class A drugs, in addition to receiving methadone treatment, during pregnancy and after Child H’s birth.


Family S11:Death of a 15-year-old boy in March 2013, as the result of an overdose of drugs prescribed to his father.

Andrew’s family was well known to services including education, children’s social care, health and child and adolescent mental health services (CAMHS). Andrew’s parents were divorced and Andrew lived with his father, who was receiving services for long-standing mental health problems at the time of the incident.

Conwy and Denbighshire: Death of a young person from an overdose of prescription medication, thought to be suicide. History of truancy and bullying, parental mental health problems and suicidal ideation.

Child FJ: Death of an adolescent girl by hanging, in the early summer of 2011. FJ became known to agencies four months before her death when she disclosed a history of self-harming to mother and GP. FJ took a significant overdose of over-the-counter medication in the months preceding her death, resulting in an eight day in-patient hospital stay.

Child F: Review into agency involvement in the case of a 2 year old girl who was admitted to hospital in 2011 with respiratory problems after ingesting methadone. The girl and her older sister were both subject to child protection plans at the time and their two older siblings had been taken into care. Parental risk factors included: drug and alcohol misuse; domestic abuse; and criminal behaviour.

Child W2: Review following allegations made by an adolescent girl in August 2010, in regard to parents’ non-compliance with the administering of medication for a serious health condition and living in unacceptable conditions. 

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