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recurance

Melvyn Blount

21 Sept 2023 · Coroner Susan Evans · Derby and Derbyshire

The coroner's concerns

  1. 1. drug alerts not communicated to non-prescribers

    “Mr [name redacted] had a consultation with a non-prescribing mental health practitioner at his GP practice who considered that he would benefit from the prescription of zopiclone. As a non prescriber he had to seek the assistance of a GP to actually prescribe the tablets and this was done after discussion between the two professionals. There was no direct contact between the GP and Mr [name redacted]. The mental health practitioner was aware of a relevant drug alert but did not inform Mr [name redacted]. From the evidence”
  2. 2. unclear responsibility for disseminating drug alerts

    “The lack of a clear policy gives rise to the risk that drug alerts are not seen by non-prescribers and therefore not communicated or are being seen or known about but still not communicated”
  3. 3. absence of procedure for alert handling by prescribing GP

    “what should happen to ensure that an alert is digested and disseminated when it is the GP who receives the alert but is prescribing at the behest of a non prescriber and so does not see the patient”

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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Melvyn Blount · Recurance