Oliver Billings
28 Nov 2024 · Coroner Luisa Nicholson · Devon, Plymouth and Torbay
The coroner's concerns
1. subsequent prescription issued after cancellation
“That a subsequent prescription was submitted in the knowledge that the first was cancelled or to be cancelled but that steps do not appear to have been taken or be able to be taken to ascertain the status of that prescription before the subsequent prescription was issued.”
2. swift medication dispatch
“That the swift dispatch of medication (whilst admittedly necessary in many circumstances) does not allow for mistakes to be noticed and/or remedied.”
3. burden on patient to correct error
“That the onus was on [the deceased] to remedy the error when Pharmacy2U could not be contacted.”