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Beatrice Gatt

18 Sept 2014 · Coroner Anne Pember · Northampton
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The coroner's concerns

  1. 1. administration of anti-psychotic clozapine medication

    “Mrs [name redacted] was not given her anti-psychotic clozapine medication due to an error in the medication not being transferred from 1 Mars sheet to another. There did not appear to be any formal training of nursing staff as to how the Mars sheet 1”

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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error