Paula Doreen
14 Oct 2025 · Coroner Liliane Field · Inner South London
The coroner's concerns
1. concurrent prescriptions of paracetamol containing drugs
“In my opinion there risk that future deaths will occur unless action is taken”
2. lack of robust process for ensuring a consistent clinical response to the management of therapeutic excess
“The Trust's response to the incident focused on prevention”
3. inconsistent ACVPU score assessment
“Mrs Hughes was scored as alert when she was confused”
4. unrecorded OTC medications causing therapeutic excess
“Mrs Hughes had taken an over the counter (OTC) drug containing paracetamol before her admission to hospital but that this had not been recorded as part of her medication history”
5. confirmation bias and lack of professional curiosity
“Confirmation bias and a lack of professional curiosity were significant features”
6. risk from virtual patient reviews without guidance
“Mrs Hughes had been reviewed virtually rather than face to face a resident doctor on the morning before she became unwell”