“It appeared in the evidence given ~~ CY that there were significant documentary failings…”
Dated 9 Mar 2015, from the coroner for Worcestershire. 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 4 May 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 dated9 Mar 2015
- Deadline4 May 2015
- Published on judiciary.uk9 Mar 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Royal Orthopaedic Hospital NHS Foundation TrustNamed in the report as “Royal Orthopaedic Hospital NHS Foundation Trust” | Response publishedPublished on judiciary.uk in March 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) It appeared in the evidence given ~~ CY that there were significant documentary failings in the control of medication at the Royal Orthopeadic Hospital. Specifically he said that there was no audit or any paper trail of the use of non-controlled medication. With regard to controlled medication it was accepted that there were documentary deficiencies which meant it could not be precisely ascertained what controlled medication had been taken or used or administered to patients. s Whilst the control of controlled medications appears ddressed by way of training and increased scrutiny and audit procedures onfirms that there is still no audit of non-controlled medication. Specifically he said that when stocks of non- controlled medication are delivered to wards and departments there is no check as to who uses the medication or for what purpose. It appears to me therefore that there is a significant opportunity for the abuse or theft of non-controlled medication. GE to!c) me that the hospital were acting in accordance with the Department of Health guidelines in the matter and that unless the Department of Health issued further guidelines there would be no change in this process. | suggest that the Trust needs to consider putting in place its own audit guidelines to ensure that what I described as a "hole" in control measures is addressed. (2) (3)
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, 2015-0088
- 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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