“Manufacturers are able to produce medication in almost identical boxes which is very…”
Dated 9 Jan 2015, from the coroner for Birmingham and Solihull. Sent to 6 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 6 Mar 2015. 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 Jan 2015
- Deadline6 Mar 2015
- Published on judiciary.uk9 Jan 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Medicines and Healthcare products Regulatory Agency | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Mar 2015. A reply may have been sent and not yet published. |
| Department of Health and Social CareNamed in the report as “Department of Health” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Mar 2015. A reply may have been sent and not yet published. |
| NHS England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Mar 2015. A reply may have been sent and not yet published. |
| General Pharmaceutical Council | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Mar 2015. A reply may have been sent and not yet published. |
| Royal Pharmaceutical Society | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Mar 2015. A reply may have been sent and not yet published. |
| Crescent Pharma Ltd | Response publishedPublished on judiciary.uk in January 2015. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
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) Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths.
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, 2015-0009
- 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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