“There may not have been a clear indication on the patients medical record about the…”
Dated 26 Oct 2023, from the coroner for Milton Keynes. 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
All responses publishedReplies were due by 21 Dec 2023.
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; a reply may have been sent and not yet published.
- Report dated26 Oct 2023
- Deadline21 Dec 2023
- Published on judiciary.uk1 Nov 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Milton Keynes University Hospital NHS Foundation TrustNamed in the report as “Milton Keynes University Hospital” | Response publishedPublished on judiciary.uk in November 2023. |
The coroner’s concerns
There may not have been a clear indication on the patients medical record about the potential risk of abuse, or for the risk to be flagged up to members of staff before discharge. This oversight raises serious questions about the hospital's processes and procedures for managing medication and patient records. I strongly urge the hospital to undertake a comprehensive review of the procedures concerning the distribution of medication. It is imperative that the hospital ensures that the potential risks and warnings are clearly marked on the patient's medical record and that all staff are made aware of any potential concerns regarding use. I believe that a thorough review of your procedures and the implementation of more robust protocols can protect the well being of patients and prevent future similar deaths.
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, 2023-0411
- 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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