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recurance

Anita Mandalia

9 Jul 2021 · Coroner Graeme Irvine · East London

The coroner's concerns

  1. 1. long-term prescription of medication contrary to NICE guidance

    “Mrs [name redacted] had been prescribed QM NICE guidance and BNF guidance stipulates that this medication ought not to be prescribed for longer than HE Mrs [name redacted] had received that prescription far longer that the recommended period. The GP surgery had not reviewed the appropriateness of that prescription.”
  2. 2. failure to refer patient for mental health concerns as instructed

    “Despite having received instructions within a discharge summary from a secondary mental health trust in August 2020 that required the surgery to re- refer Mrs [name redacted] if concerns arose regarding her mental health, when issues were raised in October and December 2020 to the surgery no referral was made”
  3. 3. inadequate control of medication supply leading to excess dosing

    “In June 2020 the surgery introduced measures to mitigate the risk of overdose presented by Mrs [name redacted] which required medication to be dispensed in a dosette box containing a maximum 7-day supply of medications. However, on 6' January 2021 Mrs [name redacted] was prescribed for pain which allowed her access to an excess of a”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Anita Mandalia · Recurance