John Fisher
19 Mar 2026 · Coroner Karen Taylor · West Sussex, Brighton and Hove
The coroner's concerns
1. medication errors in community care
“patients in the community are at risk of either being given medication that has been discontinued by a GP or not being given essential medication to control seizures”
2. inaccurate medication administration
“phenobarbital tablets twice a day even though Mr [name redacted] GP had discontinued the phenobarbital on 8 April 2025”
3. unclear medication duration
“no clear indication is given when they were to stop and may well have finished by the time Coastal took over care”
4. medication omission
“Coastal Homecare accepted that between 16 April to 21 April (6 days) Mr [name redacted] did not receive any sodium valproate oral solution”
5. inadequate medication handover process
“no system in place to cross check what has previously been given when there is a handover between different care agencies”
6. lack of learning from incidents
“no follow-up by either organisation to ascertain if there are any lessons to learn for the benefit of other vulnerable patients”