Sandra Scott
6 Nov 2019 · Coroner David Urpeth · South Yorkshire (West)
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. prescription not available for download
“The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued. Unbeknown to the GP these changes meant the prescription was no longer available for download by the chemist.”
2. delayed test results
“The results of the hospital urine test were available on the 20th April 2019 but were not acted upon at this point”
3. failure to administer medication
“The evidence was that had the patient received the medication prescribed by the GP or indicated by the hospital results, then she would not have died when she did”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“Downloading prescriptions only up to 2.30pm each day, with the aim of labelling all prescriptions downloaded on that day.”
This report
“The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued.”
Responses
No published response was found on judiciary.uk.