Francis Cooney

“Dr. , Consultant [name redacted], made a change to Mr. [name redacted] prescriptions for Amitryptyline and Nitrazepam. Although the fact of the change and the rationale for it were explained in”

“For patients with a cognitive impairment there is a risk that if changes to medication made during an inpatient stay are not communicated directly to those caring for them, confusion will arise which could result in the medication being erroneously omitted or overdose.”

“Dr. acknowledged that if Mr. [name redacted] had been a patient on the Geriatric Wards, rather than a plastic surgery patient, she would have communicated the fact and reason for change to Ms. directly. She said she did not do so in this case because, as a Consultant providing an opinion for a patient under the care of another team, she did not view it as her responsibility.”

“The Coroner is aware that this case has not been the subject of a root cause analysis or similar such investigation and is therefore concerned that the broader implications of this breakdown in communication will not have been identified.”