“I heard evidence that the administration of PD medication in hospital routinely does not…”
Dated 7 May 2014, from the coroner for Inner North London. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 2 Jul 2014.
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; a reply may have been sent and not yet published.
- Report dated7 May 2014
- Deadline2 Jul 2014
- Published on judiciary.uk7 May 2014
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University College London Hospitals NHS Foundation Trust | Response publishedPublished on judiciary.uk in May 2014. |
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The coroner’s concerns
– (1) I heard evidence that the administration of PD medication in hospital routinely does not follow patients’ usual regimens and that this, in itself, could cause physiological stress and contribute to early death. It was not possible conclude that, on the balance of probabilities, this was the case in Mr Brookes death but it was clear that this was a continuing risk, which could result in future deaths. (2) The risks posed by the unavailability of doctors for nonemergency reviews, during weekend shifts, raises concern that future deaths could occur as a consequence. (3) The cause of the dispensing error, that resulted in the wrong medication being put in a box labelled as ‘Amantadine’, was not elucidated during the inquest and raises concern that future similar errors could recur, with potential for future deaths resulting.
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, 2014-0205
- Added to Minute Book
- 8 Oct 2026
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- 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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