“There is a lack of local practitioner guidance on the practical implementation of the…”
Dated 17 May 2024, from the coroner for Lincolnshire. 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 12 Jul 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 dated17 May 2024
- Deadline12 Jul 2024
- Published on judiciary.uk20 May 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS Lincolnshire Integrated Care BoardNamed in the report as “Lincolnshire Integrated Care Board” | Response publishedPublished on judiciary.uk in May 2024. |
The coroner’s concerns
(1) There is a lack of local practitioner guidance on the practical implementation of the NICE NSAIDs - prescribing issues documentation. The software being used to prescribe NSAIDs did not automatically generate a specific warning flag to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI). Where repeat prescriptions were issued on discharge of a patient from hospital back to community primary care, there was no warning on the discharge documentation to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI). (2) (3)
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, 2024-0271
- 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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