Dawn Gill
16 Nov 2018 · Coroner ME Hassell · London Inner (North)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. risk of illicit drug use while inpatient
“Ms [name redacted] was a long term drug user and, based on her history, was likely to take illicit drugs whether she was in or out of hospital”
2. missing drug chart
“Ms [name redacted] was prescribed methadone in hospital and died of a methadone overdose, but her drug chart was not available at inquest and appears to have been lost”
3. failure to detect patient on floor
“Ms [name redacted] room was described as having been searched on numerous occasions overnight, by more than one person, the first time approximately half an hour after she had last been seen, yet her presence under clothing on the floor was not detected until 10am the following day”
4. delayed security response to missing patient
“Ms [name redacted] was thought to have left the ward for a cigarette some time before 12.30am, though she was not actually seen leaving. She was wearing her night things. When her absence was discovered, hospital security personnel were not alerted”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“Ms [name redacted] was prescribed methadone in hospital and died of a methadone overdose, but her drug chart was not available at inquest and appears to have been lost.”
Later report
“Despite awareness of the previous overdoses on the ward, there was no itemised property list, including a list of medications.”
Responses
2018-0354-Response-by-Barts-Health-NHS-Trust.pdf ↗· Royal London Hospital
Stated action · 2019-20
“The Trust is moving in 2019-20 to electronic prescribing. This will eliminate the need for paper based drug charts, and the attendant risk of them being mislaid or lost.”