Missing medication documentation
Royal London Hospital received 2 coroners' reports about this hazard between 16 Nov 2018 and 28 Feb 2022.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“Ms [name redacted] was prescribed methadone in hospital and died of a methadone overdose, but her drug chart was not available at inquest and appears to have been lost.”
Original on judiciary.uk ↗ Royal London Hospital responded, stating 1 specific action.Response (PDF) ↗
“The Trust is moving in 2019-20 to electronic prescribing. This will eliminate the need for paper based drug charts, and the attendant risk of them being mislaid or lost.”
Stated timescale: 2019-20
- 3 years 3 months laterClosely relatedConfidence 0.85 · higha different coroner
“Despite awareness of the previous overdoses on the ward, there was no itemised property list, including a list of medications.”
Original on judiciary.uk ↗ The most recent report. A response may not be due or published yet.
- All reports to Royal London Hospital
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2018 → 2022Vijaykumar Gadhavi3 years 3 months after Dawn Gill · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight failures in documenting patients' medication information, which can lead to unsafe prescribing and overdose risks. The earlier case concerned a lost paper drug chart; the later case notes the absence of an itemised property list of medications.
Dawn Gill · 16 Nov 2018
“Ms [name redacted] was prescribed methadone in hospital and died of a methadone overdose, but her drug chart was not available at inquest and appears to have been lost.”
Original on judiciary.uk ↗ Vijaykumar Gadhavi · 28 Feb 2022
“Despite awareness of the previous overdoses on the ward, there was no itemised property list, including a list of medications.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Trust is moving in 2019-20 to electronic prescribing. This will eliminate the need for paper based drug charts, and the attendant risk of them being mislaid or lost.”
Stated action · timescale: 2019-20
“The Trust is moving in 2019-20 to electronic prescribing. This will eliminate the need for paper based drug charts, and the attendant risk of them being mislaid or lost.”
No published response from Royal London Hospital was found for this report. It is the most recent report, so a response may not be due or published yet.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Royal London Hospital at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2018 → 2022 | 0.72 | 0.08 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.