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recurance

Ian Hall

14 Jun 2021 · Coroner Alison Mutch · Greater Manchester South

The coroner's concerns

  1. 1. inadvertent dispensing of Amitriptyline to vulnerable adult

    “It was unclear how Amitriptyline rather than Atenolol had been dispensed in the community”

Responses

2021-0202-Response-from-MHRA_Redacted.pdf ↗· Medicines and Healthcare products Regulatory Agency

Stated action

“The MHRA will review the packaging of these medicines and if we consider on assessment that improvements could be made we will contact any pharmaceutical manufacturers who supply these medicines and seek changes so that the likelihood of future errors of this nature may be reduced.”

2021-0202-Stockport-CCG_Redacted.pdf ↗· Stockport Clinical Commissioning Group

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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