James Nowshadi
29 Jul 2021 · Coroner Caroline Jones · Cambridgeshire and Peterborough
The coroner's concerns
1. lack of learning from Serious Incident Reviews
“there is a risk of future fatalities if mental health practitioners do not have ready access to timely and up-to-date information about the risks associated with sodium nitrate/nitrite.”
2. lack of national guidance on antidote use
“there is a risk of future fatalities if A&E clinicians do not have access to comprehensive and up-to-date information about toxic substances and their possible antidotes”
Responses
2021-0260-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2021-0260-Response-from-Royal-College-of-Psychiatrists-1.pdf ↗· Royal College of Psychiatrists
Stated action · near future
“We will look for opportunities to do this in the near future”