Recurance · prevention of future deaths reports
Pre-inquest brief
Uncontrolled prescribing of contraindicated drugs
The earlier warning
Judith Marshall · 27 Jan 2014 · William Coverdale, York
“There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors.”
judiciary.uk/prevention-of-future-death-reports/judith-marshall
What was promised
Stated action 1 · response to Judith Marshall (27 Jan 2014) · stated timescale: none stated
“Community pharmacies are required to record patient safety incidents that caused harm or have the potential to cause harm in a pharmacy errors log. They should also report these incidents to the National Reporting and Learning System (NRLS).”
What recurred
- 21 Oct 2021 · Jamie O'Connor · Dianne Hocking · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · Judith Marshall · 27 Jan 2014
“There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors.”
Later · Jamie O'Connor · 21 Oct 2021
“There is no central tracking system or central database to record what each person has been prescribed and dispensed and by whom.”
What happened next
No web check of the stated actions has been published for this chain.