Recurance · prevention of future deaths reports
Pre-inquest brief
Incomplete medication review due to missing medical records
The earlier warning
Kathleen Neville · 7 Aug 2015 · Christopher Woolley, Cardiff and the Vale of Glamorgan
“The absence of a Medication Reconciliation Policy at the University Hospital of Wales over the relevant period made it much harder for the individual failures of the admitting doctor and initial pharmacist to be picked up.”
judiciary.uk/prevention-of-future-death-reports/kathleen-neville
What was promised
No published response from NHS Wales was found for the earlier reports.
What recurred
- 16 Sept 2016 · David Phillips · Colin Phillips · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Kathleen Neville · 7 Aug 2015
“The absence of a Medication Reconciliation Policy at the University Hospital of Wales over the relevant period made it much harder for the individual failures of the admitting doctor and initial pharmacist to be picked up.”
Later · David Phillips · 16 Sept 2016
“The Health Care Professional did not have access to detainee's medical records to accurately identify reasons as to why and how medications are changed or as to when this may or may not have occurred.”
What happened next
No web check of the stated actions has been published for this chain.