Recurance · prevention of future deaths reports
Pre-inquest brief
Prescription download unavailable leading to medication delay
The earlier warning
Douglas Hodges · 12 Oct 2017 · Heidi Connor, Nottinghamshire
“Downloading prescriptions only up to 2.30pm each day, with the aim of labelling all prescriptions downloaded on that day.”
judiciary.uk/prevention-of-future-death-reports/douglas-hodges
What was promised
Stated action 1 · response to Douglas Hodges (12 Oct 2017) · stated timescale: up to 24 months
“The EPS Enhancements survey took place in August 2017 and a”
Stated action 2 · response to Douglas Hodges (12 Oct 2017) · stated timescale: none stated
“An improved reporting mechanism has been developed to record actions and results of the audit and support the ongoing maintenance of the changes which have been implemented.”
What recurred
- 6 Nov 2019 · Sandra Scott · David Urpeth · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Douglas Hodges · 12 Oct 2017
“Downloading prescriptions only up to 2.30pm each day, with the aim of labelling all prescriptions downloaded on that day.”
Later · Sandra Scott · 6 Nov 2019
“The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued.”
What happened next
No web check of the stated actions has been published for this chain.