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Jerome Peat

8 Feb 2021 · Coroner Dr Simon Fox QC · Avon
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The coroner's concerns

  1. 1. inadvertent duplication of morphine prescription leading to overdose

    “The EMIS computer medical record on 4.11.19 failed to alert J at Long Furlong Medical Centre that Mr [name redacted] had already registered with the GP at the Student Medical Centre, as a result of which there was inadvertent duplication of his morphine prescription on 4.11.19 and 5.11.19 and Mr [name redacted] was prescribed significantly more morphine than was intended. He subsequently died from an overdose of Telephone”

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