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recurance

Maureen Chatterley

8 Oct 2015 · Coroner Alan Walsh · Manchester (West)

The coroner's concerns

  1. 1. stock control failure of non-controlled medication

    “There was no investigation by the hospital in relation to the concerns expressed by the family in relation to the administration of an excess dose of Lorazepam. There was no record of the stock of medication in relation to non-controlled drugs in the medication drawer allocated to a patient nor in and the medication cupboard on the ward. Accordingly medication could be removed from the medication cupboard on the ward and used either for an elicit purpose or excess dosage without any knowledge or”
  2. 2. inadequate medication security and stock control

    “The procedures in relation to the supply, security and safe keeping of medication on wards at the Royal Bolton Hospital. Stock control and a record of medications both in the medication drawers allocated to individual patients and in cupboards on wards at the Royal Bolton Hospital to enable the medications and the quantities of medications to be identified and verified, both in the medication drawers and in the cupboards on the ward, at any point in time.”

Responses

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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.

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Maureen Chatterley · Recurance