Recurance · prevention of future deaths reports
Pre-inquest brief
Inconsistent medication quantity documentation and unrecorded stock
The earlier warning
Rachel Edwards · 27 Feb 2017 · Nigel Parsley, Suffolk
“Such confusion over the actual quantities of medication Issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a View to self-harm, is of obvious concern.”
judiciary.uk/…/rachel-edwards-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Rachel Edwards (27 Feb 2017) · stated timescale: none stated
“The Trust will make an assessment of the medications prescribed upon discharge and this consideration will continue across the Trust.”
judiciary.uk/…/2024-0220-Response-from-Norfolk-and-Suffolk-NHS-…
What recurred
- 26 Sept 2022 · Lewis Begley · Jacqueline Lake · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Rachel Edwards · 27 Feb 2017
“Such confusion over the actual quantities of medication Issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a View to self-harm, is of obvious concern.”
Later · Lewis Begley · 26 Sept 2022
“Evidence was heard that medication is kept in a locked room and in locked cabinets, in accordance with legislation. However, there is no record kept as to what medication is stored and how much”
What happened next
No web check of the stated actions has been published for this chain.