“The circumstances in which the methadone was prescribed namely: (1) Doing so over the…”
Dated 29 Mar 2017, from the coroner for South Yorkshire East. 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 24 May 2017. 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 dated29 Mar 2017
- Deadline24 May 2017
- Published on judiciary.uk21 Apr 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Dinnington Group Practice | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 24 May 2017. A reply may have been sent and not yet published. |
| Yorkshire Ambulance Service NHS TrustNamed in the report as “Yorkshire Ambulance Service NHS Foundation Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 24 May 2017. 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.
— The circumstances in which the methadone was prescribed namely: (1) Doing so over the telephone with no face to face consultation. (2) Consequent lack of detail regarding: 2.1 the drugs being taken by Miss Holt 2.2 the frequency with which they were being taken 2.3 the degree if any, of her dependence 2.4 absence of assessment of any psychological issues (3) Providing a methadone naive patient with a 7 day supply. (4) Lack of medical review during the initial phase.
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, 2017-0096
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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