Judith Saville

“In his evidence IE told the Court that Mrs [name redacted] death had been reviewed at a significant events meeting in his practice. | was told that it was felt he had prescribed too much medication, particularly in a person who had a past medical history that included overdoses of prescribed medication. MEN said that there was now an increased awareness on the Practitioners not to prescribe so much medication in similar circumstances. He felt that a supply of no more than a week's worth of medication”

“HEE saici that the system could be made more robtist by introducing a warning on the firm's computer system. This would assist Practitioners by drawing to their attention a past medical history of overdose. It was felt that this may particularly be of benefit to locum doctors who would not necessarily have the same recall of a patient as a partner in the practice.”

“The Inquest heard evidence from MEE wo had conducted a Root Cause Analysis into the circumstances of Mrs [name redacted] death. A copy of that Report is attached. HE gave evidence that there were a number of lessons to be learned and that an action plan had been drafted. At inquest | expressed my concern that the action plan was implemented and its effectiveness subsequently audited.”