Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of centralised prescription database
The earlier warning
Deborah Headspeath · 18 Nov 2019 · Nigel Parsley, Suffolk
“There is no single database that allows a prescribing clinician to identify what prescription only medication has already been prescribed to any particular patient.”
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 21 Oct 2021 · Jamie O'Connor · Dianne Hocking · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · Deborah Headspeath · 18 Nov 2019
“There is no single database that allows a prescribing clinician to identify what prescription only medication has already been prescribed to any particular patient.”
Later · Jamie O'Connor · 21 Oct 2021
“There is no central tracking system or central database to record what each person has been prescribed and dispensed and by whom.”
What happened next
No web check of the stated actions has been published for this chain.