Rachel Edwards
27 Feb 2017 · Coroner Nigel Parsley · Suffolk
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. stockpiling of medication leading to overdose
“Prior to [the deceased]'s death, on the 6th March 2017 she was informally admitted to the Woodlands mental health ward In Ipswich following a significant overdose she had taken on the 3rd March 2017”
2. inadequate medication disposal
“It was known that [the deceased] was at risk of stockpiling medication as in the Serious Incident Requiring Investigation (SIRI) report it is noted that a request made on the 7th March 2017 by her treating doctor, for the disposal of her stocks of medication had not been actioned”
3. inconsistent medication quantity documentation
“Such confusion over the actual quantities of medication Issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a View to self-harm, is of obvious concern”
4. lack of automated discharge medication notification
“there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands”
5. absence of patient advocacy system
“no 'patient advocate' or other similar service in place to act as filter and alert those providing support to prepare for the increased feeling of hopelessness that would clearly follow such news”
6. lack of formal patient advocate appointment process
“no formal system in place for an advocate to be appointed in other cases when it could prove beneficial”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands”
Later report
“An initial full, updating letter was sent to [the deceased]'s GP. However no further updating information was sent.”
Closely relatedConfidence 0.80 · moderate
This report
“Such confusion over the actual quantities of medication Issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a View to self-harm, is of obvious concern.”
Later report
“Evidence was heard that medication is kept in a locked room and in locked cabinets, in accordance with legislation. However, there is no record kept as to what medication is stored and how much”
Responses
2024-0220-Response-from-Norfolk-and-Suffolk-NHS-Foundation-Trust.pdf ↗· Norfolk and Suffolk NHS Foundation Trust
Stated action
“The Trust will make an assessment of the medications prescribed upon discharge and this consideration will continue across the Trust.”