“Evidence given at the inquest revealed that the system at the GP practice when examined…”

The coroner’s concerns

– (1) Evidence given at the inquest revealed that the system at the GP practice when examined by the pharmacist at the hospital did not show that the Oromorph prescription had been stopped. (2) Evidence was heard that Mrs. Few whilst an in patient was prescribed Oromorph and not Zoromorph the drug she had been using at 20mg twice a day. The effect of which may have impacted upon her pain control but the evidence did not show she had high pain scores. A pharmacist recognised this discrepancy on 8th March and asked for this to be reviewed. No such review took place and it was difficult to see on the electronic records system that such a review needed to take place as apparently there were no highlights or flags to alert the doctors that such a review needed to take place. (3) At the inquest it was clear that the standard of record keeping by the medical staff was poor and it was only by hearing from witnesses via statements and orally, including from her family, that the decision making around her care and plans for her management became clear, as there was very little written in the notes. In particular there was no evidence of why decisions were made, what discussions were held and what advice was given.

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, 2022-0366

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0