Fred Whittaker

14 Jul 2016 · Coroner Andrew Bridgman · Manchester (South)

The coroner's concerns

1. continued prescription of Cionazepam
“An important issue in the Inquest was the continued prescription of Cionazepam by the Heaton Moor Medical Centre despite the written request on 17”
2. lack of recording of reasons for stopping medication
“On receipt of request the drug was moved from the Repeat Prescription list to the Past Prescription list, without any reference in the records of the reason as to why the Clonazepam was being stopped”
3. error in prescription management
“This is clearly an unacceptable error”
4. absence of standard directions
“there were no standard directions as to how to manage this as a situation and that other practices may adopt the same simple policy of transferring the drug from one list to another”

Stated action

“NHS England will share this learning and best practice further with GPs.”