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recurance

Sarah Brady

5 May 2021 · Coroner Joanne Lees · Black Country

The coroner's concerns

  1. 1. long history of chronic pain and mental health problems

    “Mrs [name redacted] had a long history of Chronic pain, mental health problems and informal admissions in Psychiatric hospitals. She had a recent history of intentional medication overdose in March 2020 and erratic compliance with her medications.”
  2. 2. 7 day prescription limit

    “Due to the above, Mrs [name redacted] GP was only issuing 7 day prescriptions due to her high risk of overdose in order to limit medication availability. This included amongst others.”
  3. 3. prescription issued before discharge

    “Mrs [name redacted] had already been issued with a prescription by her GP on 14/7/20 for her regular prescription medication;”
  4. 4. excessive prescription beyond 7 days

    “I am concerned that Mrs [name redacted] was issued with a prescription in excess of 7 days and for medication that had already been prescribed to her by her GP only the previous day and against a background of overdose and erratic compliance with her medications;”
  5. 5. medication stockpiling

    “The levels of found as a result of qualitative testing appeared to be well in in excess of her prescriptions and there was evidence that Mrs [name redacted] may have been stockpiling medication. It is possible that the additional prescription, if supplied may have formed part of the medication taken by way of overdose.”
  6. 6. unfulfilled prescription

    “another similar prescription issued on 28/7/20 following a further admission had NOT been fulfilled”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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