“The doctor who prescribed the morphine at Queens Hospital had not appreciated that the…”
Dated 19 Dec 2019, from the coroner for East London. 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
Deadline passedReplies were due by 13 Feb 2020. 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 dated19 Dec 2019
- Deadline13 Feb 2020
- Published on judiciary.uk3 Jan 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Barking, Havering and Redbridge University Hospitals NHS TrustNamed in the report as “Barking, Havering & Redbridge University Hospitals NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 13 Feb 2020. 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 doctor who prescribed the morphine at Queens Hospital had not appreciated that the London Ambulance Service paramedics had administered 20 milligrams of morphine. If he had been aware of this he would not have administered a further 10 milligrams. The doctor did not note that the paramedics had referred to mls as opposed || to mgs in the medication section of the Patient Report Form. The doctor _ the units used in hospital are mgs. | It was agreed by all witnesses that great care needs to be taken in the administration of | | Opiate medication. it Was agreed that the use of different units by the pre-hospital ) a — | 6 | ACTION SHOULD BE TAKEN | | | | In my opinion action Should be taken to Prevent future deaths and | believe you have the | | power to take such action. ' '7 | YOUR RESPONSE | | You are under a duty to respond to this report within 56 days of the date of this report, | | Namely 12° February 2020. |, the coroner, may extend the period. — i | | Your response must contain details of action taken or proposed to be taken, Setting out | | the timetable for action. Otherwise you must explain why no action is proposed. | pee ee 8 | COPIES and PUBLICATION | | have sent a copy of my report to the Chief Coroner and to Gacshter of the | deceased), the London Ambulance Service, Care Quality Commission and Director of | | Public Health. | | 1am also under a duty to send the Chief Coroner a copy of your response. | The Chief Coroner May publish either or both in a complete or redacted or summary | form. He may send a copy of this report to any person who he believes May find it useful | | | Or of interest. You may make representations to me, the coroner, at the time of your | | | response, about the release or the publication of your response by the Chief Coroner. a | 9 | 19/12/2019 NM
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, 2019-0444
- 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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