“I am concerned that measures are not in place at Macklin Street Surgery and Daynight…”
Dated 25 Nov 2024, from the coroner for Derby and Derbyshire. Sent to 4 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 20 Jan 2025. A reply may have been sent and not yet published.
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.
- Report dated25 Nov 2024
- Deadline20 Jan 2025
- Published on judiciary.uk27 Nov 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Macklin Street Surgery | Response publishedPublished on judiciary.uk in November 2024. |
| Daynight Pharmacy | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 20 Jan 2025. A reply may have been sent and not yet published. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in November 2024. |
| NHS Derby and Derbyshire Integrated Care Board | Response publishedPublished on judiciary.uk in November 2024. |
The coroner’s concerns
- I am concerned that measures are not in place at Macklin Street Surgery and Daynight pharmacy to prevent prescription of excess medication to patient’s recognised to be at risk of overdose, either intentional or unintentional, who are ordinarily issued shorter period repeat prescriptions to reduce those risks. This situation arises when early prescriptions are issued due to statutory holiday periods when most pharmacies are likely to be closed. I have been informed that measures have been introduced to prevent excess prescribing by taking account of single day bank holidays, but there are no measures relating to longer bank holiday periods (e.g. Easter). With electronic patient record and data systems it seems a reasonable presumption that suitable solutions can be identified. As I imagine that the substance of my concern is likely to apply to other GP practices and pharmacies, I have also sent this report to the Department of Health and Social Care and NHS Derby and Derbyshire Integrated Care Board.
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, 2024-0644
- 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
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