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recurance

Denise Parramore

19 May 2014 · Coroner Donald Coutts-Wood · South Yorkshire (West)

The coroner's concerns

  1. 1. lack of communication between primary and secondary care

    “The Psychiatric Services, and in particular her Consultant [name redacted], was not aware, prior to [the deceased]'s death, of her being prescribed Tramadol by her General Practitioner. Concerns would have been raised, and action likely taken, if she had been aware. The Consultant [name redacted] was not informed either by Mrs [name redacted] herself, nor the General Practitioner of the prescribing of the Tramadol. My concern is that there should be open, and constant two-way communication between those”
  2. 2. lack of documentation sharing

    “For the same reasons as given above, will it be possible for those in primary and secondary care access each other's documentation, which would likely have revealed the prescribing.”

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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Denise Parramore · Recurance