Recurance · prevention of future deaths reports
Pre-inquest brief
Inconsistent medication administration timing
The earlier warning
Raymond Woodhouse · 21 Oct 2020 · Andrew Cox, Cornwall and the Isles of Scilly
“'multiple' occasions when medication was given late and three occasions when it was not given at all”
What was promised
No published response from Royal Cornwall Hospital was found for the earlier reports.
What recurred
- 11 Nov 2025 · Tracey Oldfield · Andrew Cox · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Raymond Woodhouse · 21 Oct 2020
“'multiple' occasions when medication was given late and three occasions when it was not given at all”
Later · Tracey Oldfield · 11 Nov 2025
“need for patients who are admitted late and unexpectedly (of which the PSII recorded there are over 1,000 annually) to have their usual medication prescribed in timely fashion.”
What happened next
No web check of the stated actions has been published for this chain.