“are: a”
Dated 19 Aug 2025, from the coroner for Surrey. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 14 Oct 2025. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated19 Aug 2025
- Deadline14 Oct 2025
- Published on judiciary.uk29 Aug 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Medicines and Healthcare products Regulatory AgencyNamed in the report as “Medicines and Healthcare Products Regulatory Agency (MHRA)” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 14 Oct 2025. A reply may have been sent and not yet published. |
| EMIS Health | Response publishedPublished on judiciary.uk in August 2025. |
The coroner’s concerns
are: a. The MHRA issued a drug safety alert regarding the risks of pulmonary and hepatic adverse drug reactions in relation to nitrofurantoin in April 2023. However, no MHRA safety alert appeared on the surgery EMIS system when the drug was prescribed to Mrs Pierce. The court heard that the safety alert only arises when patients have a pre-existing pulmonary disease which Mrs Pierce did not have. b. Although a “recognised” complication, understanding of the potential for pulmonary damage and respiratory failure from use of nitrofurantoin in the elderly may remain low. The court heard evidence from a respiratory consultant that awareness amongst GPs, hospital clinicians including urologists was limited and that even if Mrs Pierce had been referred to hospital earlier the condition might not have been diagnosed.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0427
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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