Janice Davies
31 Dec 2018 · Coroner Graeme Hughes · South Wales Central
The coroner's concerns
1. lack of documented observations after oramorph administration
“There was an absence of documented (despite indicated) observations of the deceased post her doses of oramorph at around 13:55 hrs & 15.40 hrs on 19.4.18”
2. missing pain score before discharge
“There was an absence of an updated & documented pain score prior to discharge”
3. lack of formal prescribing guidance for oramorph
“there appeared, on the evidence, to be an absence of formal guidance or instruction- written or otherwise to clinicians in the Accident & Emergency Department regarding the prescribing of oramorph to discharging patients.”