Sally-Ann Few
15 Nov 2022 · Coroner Catherine Wood · Mid Kent and Medway
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. prescription not shown as stopped
“Evidence given at the inquest revealed that the system at the GP practice when examined by the pharmacist at the hospital did not show that the Oromorph prescription had been stopped.”
2. inappropriate opioid prescribed
“Evidence was heard that Mrs. [name redacted] whilst an in patient was prescribed Oromorph and not Zoromorph the drug she had been using at 20mg twice a day.”
3. poor record keeping
“At the inquest it was clear that the standard of record keeping by the medical staff was poor and it was only by hearing from witnesses via statements and orally, including from her family, that the decision making around her care and plans for her management became clear, as there was very little written in the notes.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“Medical records were inconsistent and / or incomplete leading to a lack of clarity as to reviews and care plan.”
This report
“At the inquest it was clear that the standard of record keeping by the medical staff was poor”
Identical hazardConfidence 0.90 · high
Earlier report
“Whomever attended (if they anybody did in fact attend), did not make any entry into Mrs [name redacted] medical records”
This report
“At the inquest it was clear that the standard of record keeping by the medical staff was poor and it was only by hearing from witnesses via statements and orally, including from her family, that the decision making around her care and plans for her management became clear, as there was very little written in the notes.”
Responses
2022-0366-Response-from-Medway-NHS-Foundation-Trust.pdf ↗· Medway NHS Foundation Trust
Stated action
“The Trust Pharmacy team has contacted representatives of the Kent & Medway ICB Medicines Optimisation team that cover Medway & Swale. They are currently investigating the review process by the pharmacist to understand how the dose and product changes made were recorded and communicated to the GP practice. They are also investigating why these changes did not appear in the Kent Summary of Care Record.”