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Doris Clark

19 Dec 2019 · Coroner Nadia Persaud · London (East)
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The coroner's concerns

  1. 1. inconsistent units of measurement for opiate medication

    “The doctor who prescribed the morphine at Queens Hospital had not appreciated that the London Ambulance Service paramedics had administered 20 milligrams of morphine. If he had been aware of this he would not have administered a further 10 milligrams. The doctor did not note that the paramedics had referred to mls as opposed to mgs in the medication section of the Patient Report Form. The doctor confirmed that the units used in hospital are mgs. It was agreed by all witnesses that great care needs”

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