Mark Smith
24 Sept 2025 · Coroner Sean Horstead · Essex
The coroner's concerns
1. lack of medication review system for vulnerable patients
“there continued to be no system, policy or process in place, to ensure that vulnerable patients with a history of addiction and/or self-harm and/or suicidal ideation and/or prescription medication overdose received or receive appropriate medication reviews to consider the frequency and volume of repeat prescribed medication”