“Mrs Brady had a long history of Chronic pain, mental health problems and informal…”
Dated 5 May 2021, from the coroner for Black Country. 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 8 Jul 2021, after the 56 days for replies had ended (30 Jun 2021). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated5 May 2021
- Deadline30 Jun 2021
- Published on judiciary.uk8 Jul 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sandwell and West Birmingham Hospitals NHS TrustNamed in the report as “Sandwell and West Birmingham Hospital Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
– (1) Mrs Brady had a long history of Chronic pain, mental health problems and informal admissions in Psychiatric hospitals. She had a recent history of intentional medication overdose in March 2020 and erratic compliance with her medications. (2) Due to the above, Mrs Brady’s GP was only issuing 7 day prescriptions due to her high risk of overdose in order to limit medication availability. This included amongst others. (3) Mrs Brady had already been issued with a prescription by her GP on 14/7/20 for her regular prescription medication; (4) The inquest heard evidence that following a hospital admission in early July 2020, Mrs Brady was medically fit for discharge on 15/7/20 and a prescription was issued by the Sandwell & West Birmingham Hospital Trust for 14 days of (4) It was unclear from the evidence whether the prescription had actually been fulfilled by the hospital. I am concerned that Mrs Brady was issued with a prescription in excess of 7 days and for medication that had already been prescribed to her by her GP only the previous day and against a background of overdose and erratic compliance with her medications; (5) The levels of found as a result of qualitative testing appeared to be well in in excess of her prescriptions and there was evidence that Mrs Brady may have been stockpiling medication. It is possible that the additional prescription, if supplied may have formed part of the medication taken by way of overdose. (6) I heard at inquest that another similar prescription issued on 28/7/20 following a further admission had NOT been fulfilled.
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, 2021-0224
- 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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