“The medication was not secured, and was prescribed in sufficient quantity for a fatal…”
Dated 9 Jul 2014, from the coroner for Exeter and Greater Devon. 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 3 Sep 2014. 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 dated9 Jul 2014
- Deadline3 Sep 2014
- Published on judiciary.uk9 Jul 2014
- Today24 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS Devon Clinical Commissioning GroupNamed in the report as “Devon Clinical Commissioning Group” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 3 Sep 2014. A reply may have been sent and not yet published. |
| Drug and Alcohol Team Devon | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 3 Sep 2014. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) The medication was not secured, and was prescribed in sufficient quantity for a fatal dose to be taken by a user un-used fo this medication. (bottle 420m1) (2) the person to whom it was prescribed appeared to be unaware of the dangers of this medication, when taken by another in large quantities. (3) Consideration should be given to the appropriateness of prescribing to an individual who is not able or prepared to keep the medication safe and secure, or is not aware of the dangers of ingestion, (deliberate or otherwise), for others. If this means daily prescription, the balance of inconvenience versus the safety of others should be carefully weighed on an individual basis, and evidence recorded in this regard.
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, 2014-0319
- 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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