Recurance · prevention of future deaths reports
Pre-inquest brief
Missing medication documentation
The earlier warning
Dawn Gill · 16 Nov 2018 · ME Hassell, London Inner (North)
“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.”
What was promised
Stated action 1 · response to Dawn Gill (16 Nov 2018) · stated 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.”
judiciary.uk/…/2018-0354-Response-by-Barts-Health-NHS-Trust.pdf
What recurred
- 28 Feb 2022 · Vijaykumar Gadhavi · Nadia Persaud · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.