Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of automated medication compliance alerts
The earlier warning
Jason Lawson · 9 Jan 2015 · Robert Chapman, Rutland & North Leicestershire
“The current system relies on healthcare staff/pharmacy staff recognising that prisoners have not attended to collect their prescription, without having a computer driven system to flag up non-attendance.”
judiciary.uk/prevention-of-future-death-reports/jason-lawson
What was promised
No published response from NHS England was found for the earlier reports.
What recurred
- 16 Nov 2023 · John Singleton · Kate Ainge · Identical hazard · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Jason Lawson · 9 Jan 2015
“The current system relies on healthcare staff/pharmacy staff recognising that prisoners have not attended to collect their prescription, without having a computer driven system to flag up non-attendance.”
Later · John Singleton · 16 Nov 2023
“An automated flag alert via the system upon the failure to dispense or collect medication by a prisoner would be a far more efficient and effective way in which prisoners failing to comply with medications could be identified and actioned quickly and in which future deaths could be prevented.”
What happened next
No web check of the stated actions has been published for this chain.