Peter Brookes
7 May 2014 · Coroner R Brittain · London Inner (North)
The coroner's concerns
1. administration of PD medication not following usual regimens
“I heard evidence that the administration of PD medication in hospital routinely does not follow patients' usual regimens and that this, in itself, could cause physiological stress and contribute to early death”
2. unavailability of doctors for nonemergency reviews during weekend shifts
“The risks posed by the unavailability of doctors for nonemergency reviews, during weekend shifts, raises concern that future deaths could occur as a consequence”
3. dispensing error resulting in wrong medication labelled as Amantadine
“The cause of the dispensing error, that resulted in the wrong medication being put in a box labelled as 'Amantadine', was not elucidated during the inquest and raises concern that future similar errors could recur, with potential for future deaths resulting”
Responses
2014-0205-Response-by-University-College-London-Hospitals-NHS-Foundation-Trust.pdf ↗· University College London Hospitals NHS Trust
Stated action · July 2014
“An item to be included in the July Quality and Safety newsletter. Link to Parkinson's Disease website and reference to 'Get it on time' video to be included in the Q&S newsletter. Awareness to be raised via the Trust Clinical Practice Facilitators forum.”