“Evidence was heard that medication is kept in a locked room and in locked cabinets, in…”
Dated 26 Sep 2022, from the coroner for Norfolk. 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.
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All responses publishedOrganisations 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 dated26 Sep 2022
- Deadline21 Nov 2022
- Published on judiciary.uk25 Nov 2022
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Norfolk and Suffolk NHS Foundation Trust | Response publishedPublished on judiciary.uk in November 2022. |
The coroner’s concerns
1. Evidence was heard that medication is kept in a locked room and in locked cabinets, in accordance with legislation. However, there is no record kept as to what medication is stored and how much, particularly which is a drug subject to misuse, in a mental health hospital where many patients have a history of drug misuse and suicidal ideation and actively seek out the drugs cupboard. 2. On a patient accessing medication, there is no knowledge as to whether anything has been taken and if so, how much, thereby limiting knowledge as to what treatment is to be considered and what action to be taken 3. Evidence was heard that there is no fixed training given to doctors with regard to the administering of in the event of there being a suspected drugs overdose.
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, 2022-0380
- Added to Minute Book
- 8 Oct 2026
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- 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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