David Potts
26 Nov 2019 · Coroner Yvonne Blake · Norfolk
The coroner's concerns
1. delayed administration of reversal medication
“That the prescription of Beriplex was not given in a timely manner”
2. lack of verification of medication administration
“That no-one checked that it had been given despite an extension of the bleed”
3. unclear medication administration and patient location tracking
“That no-one seemed to know why it was not given as ordered or where Mr [name redacted] was on the day in question”
Responses
No published response was found on judiciary.uk.