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recurance

Theresa Robertson

6 Aug 2020 · Coroner Graeme Irvine · East London

The coroner's concerns

  1. 1. lack of documentation of telephone calls

    “The surgery admitted that no documentary record was taken of two critically important telephone calls between and the surgery regarding the deceased.”
  2. 2. prescription longer than allowed

    “On 30th April 2019 Dr acted outwith the surgery guidance to allow high risk patients a prescription for medication for over 7 days in length.”
  3. 3. missing consultation record

    “The Surgery could not produce a meaningful record of Dr consultation held with Ms [name redacted] on 30th April 2019 setting out the reasons for re- starting her 28 day prescription”
  4. 4. no audit of patient records

    “Dr could not reassure the Court that any steps had been taken to audit the patient records to determine whether any other high risk patients were receiving prescriptions outside of the constraints of the surgery policy.”

Responses

No published response was found on judiciary.uk.

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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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