“in relation to on-line prescribing are as follows:(1) Whilst each individual pharmacy had…”

The coroner’s concerns

in relation to on-line prescribing are as follows:(1) Whilst each individual pharmacy had in-house safety checks to safeguard against overprescribing by their own pharmacy, there is no integrated system in place which would alert a prescriber to prescriptions that have been dispensed by other on-line pharmacies. As a result, it is currently possible for a patient to obtain excessive quantities of medication by simply placing multiple orders with different on-line pharmacists. (2) There is no requirement for the on-line pharmacies to share information with the patients GP. This means that, in the absence of the patient’s consent to share information, the online prescriber is reliant on the accuracy and truthfulness of the history provided by the patient. (3) Lack of information sharing also creates a risk that a GP or Pharmacist Prescriber may unwittingly prescribe a medication that is contraindicated with a medication that has been dispensed through an on-line pharmacy. The MATTERS OF CONCERN in relation to the provision of mental health care on Griffin Ward are as follows:(1) The Recovery & Discharge Plans contained inaccurate information regarding Ania’s consent to share information with her mother. The evidence was that this was an entry made in error in June 2020 and was not picked up by any of the nurses who updated the Recovery & Discharge Plan over the subsequent 11 months. (2) The Recovery & Discharge Plans did not address the risks associated with Ania’s procurement of Prbpranolol from on-line pharmacies. The evidence was that an update of the Recovery & Discharge Plan involved members of nursing staff simply adding a note that the overdoses had taken place. The Plan did not show that any meaningful thought had been given to addressing the particular risk associated with the procurement of on-line medication. (3) Mandatory refresher training on basic aspects of nursing care such as record keeping, searches, care-planning, undertaking pre- and post-leave assessments and confidentiality is not provided to staff. L (4) There is no requirement for the outcome of negative personal searches to be documented in the records and consequently there is no ability to effectively audit whether searches are taking place and the treating team are unable to assess a patient’s level of compliance with rules around bringing contraband items onto the ward. (5) Searches undertaken of Ania’s room following the overdoses on 10 March and 5 June 2021 were ineffective and did not uncover the Propranolol that Ania had been stockpiling. (6) Documentation on which 1:5 observations are recorded does not evidence that a check has taken place every 5 minutes. Instead the current documentation, simply requires one signature per hour. There is therefore no mechanism by which observations can be effectively audited. (7) There is no requirement to make a separate entry evidencing that a post-leave assessment has been undertaking. The post-leave assessments are currently subsumed within Day Notes and do not clearly state whether an assessment was undertaken, what was discussed and the outcome of the assessment.

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, 2023-0046

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