“For the attention A in his evidence IE told the Court that Mrs Saville’s death had been…”
Dated 15 Jan 2015, 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
All responses publishedReplies were due by 12 Mar 2015.
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 dated15 Jan 2015
- Deadline12 Mar 2015
- Published on judiciary.uk15 Jan 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Axminster Medical Practice | Response publishedPublished on judiciary.uk in January 2015. |
| Devon Partnership NHS Trust | 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) For the attention A in his evidence IE told the Court that Mrs Saville’s death had been reviewed at a significant events meeting in his practice. | was told that it was felt he had prescribed too much medication, particularly in a person who had a past medical history that included overdoses of prescribed medication. WES said that there was now an increased awareness on the Practitioners not to prescribe so much medication in similar circumstances. He felt that a supply of no more than a week's worth of medication would be appropriate. GEE said that the system could be made more robust by introducing a warning on the firm’s computer system. This would assist Practitioners by drawing to their attention a past medical history of overdose. it was felt that this may particularly be of benefit to locum doctors who would not necessarily have the same recall of a patient as a partner in the practice. (2) For the attention of Melanie Walker The Inquest heard evidence from MEE vino had conducted a Root Cause Analysis into the circumstances of Mrs Saville’s death. A copy of that Report is attached. GE ge evidence that there were a number of lessons to be learned and that an action plan had been drafted. At Inquest | expressed my concern that the action plan was implemented and its effectiveness subsequently audited.
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, 2015-0011
- Added to Minute Book
- 8 Oct 2026
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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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