“Lack of compliance with the target of 12-15 monthly medication reviews in Health Board…”
Dated 14 Feb 2024, from the coroner for North West Wales. 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 10 Apr 2024.
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 dated14 Feb 2024
- Deadline10 Apr 2024
- Published on judiciary.uk22 Feb 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Betsi Cadwaladr University Health Board | Response publishedPublished on judiciary.uk in February 2024. |
The coroner’s concerns
– (1) Lack of compliance with the target of 12-15 monthly medication reviews in Health Board managed GP practices. (2) No standard practice for medication reviews leading to a lack assurance that all pertinent matters will be covered and the approach varying between clinicians and practices. (3) The risk of inadvertent overdose in individuals like Ms Bennett, where medication that can cause e.g drowsiness and fatigue, is prescribed alongside strong opiates and other drugs that have the ability to depress the central nervous system when such medicines are prescribed without regular reviews nor specific advice in respect of the associated risks issued to patients e.g in Ms Bennett’s case, she was instructed to simply “remove old patch and apply new patch every 72 hours” Coroner's Office, Shirehall Street, CAERNARFON, Gwynedd, LL55 1SH
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, 2024-0081
- 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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