Lee Winslow

17 Aug 2022 · Coroner Chris Morris · Manchester South

The coroner's concerns

1. misappropriation of medicines by staff
“Following the admission by Dr [name redacted] in 2020 that he had taken medicines from the Trust with a view to ending his life, it is a matter of concern that the case was not formally referred to the Police and the General Medical Council”
2. unauthorised private practice during sick leave
“In December 2020, the Trust became aware that, whilst on sick leave from the NHS, Dr [name redacted] had continued with his private practice notwithstanding an explicit instruction from his manager to the effect that he should refrain from all work”
3. lack of external review of medication theft
“In the absence of any meaningful external review of the case as a whole, it is a particular concern that most of the actions which followed the theft of medication by Dr [name redacted] in 2020 appear to have been taken as a result of decisions made by members of the Trust's medical hierarchy”
4. absence of multidisciplinary oversight
“In view of the gravity of the issues raised by Dr [name redacted] misappropriation of drugs in 2020, and the previous suicide of a Consultant [name redacted] employed by the Trust involving misuse of prescription medicines, it is a matter of concern that a more multi-disciplinary approach was not taken, perhaps overseen by someone such as a non-executive director of the organisation”