Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Annette Charlton · 9 Jan 2015 · Louise Hunt, Birmingham & Solihull
“Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths.”
judiciary.uk/prevention-of-future-death-reports/annette-charlton
What was promised
Stated action 1 · response to Victor Hall (16 Oct 2019) · stated timescale: immediate effect
“Introducing library conditions within the dispensary. Commencing with immediate effect.”
judiciary.uk/…/2019-0482-Response-by-Northern-Care-Alliance-NHs…
Stated action 2 · response to Victor Hall (16 Oct 2019) · stated timescale: 31st January 2020
“the exit route (after 5pm) from the 31st January department which is currently located next to the 2020 accuracy checking area. Staff will exit the department via the pharmacy reception exit, preventing staff using the dispensary as a thoroughfare”
judiciary.uk/…/2019-0482-Response-by-Northern-Care-Alliance-NHs…
Stated action 3 · response to Victor Hall (16 Oct 2019) · stated timescale: 29th February 2020
“Reviewing the layout of the dispensary with the aim 29th February of separating the areas used for different parts of 2020 the dispensing process and improving the flow of work.”
judiciary.uk/…/2019-0482-Response-by-Northern-Care-Alliance-NHs…
2 further stated actions are listed on the full chain page.
What recurred
- 16 Oct 2019 · Victor Hall · Rachel Syed · Closely related · confidence 0.90 (high)
- 20 Jun 2023 · Anita Graves · Adrian Farrow · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Annette Charlton · 9 Jan 2015
“Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths.”
Later · Victor Hall · 16 Oct 2019
“The Pharmacy and Nursing Matron [name redacted], concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label.”
What happened next
No web check of the stated actions has been published for this chain.