Jacqueline Elliott

“The GP practice computer recording system showed drugs that were clearly on repeat prescription as drugs that were acute prescriptions. As a result the inquest was told that the medication reviews carried out would not pick up on and would not review those prescriptions. The medication reviewer would not therefore have a full overview of her prescribed long term medication”

“The notes made by GPs and the ANP who had seen her/had telephone consultations lacked detail and so it was difficult to assess what information had been provided previously and what advice she had been given”

“There was no detail provided in the notes at the inquest of the extent or issues considered during the medication reviews that were recorded as having taken place”

“There was a recorded history of non-compliance and deliberate self-overmedication of painkillers by Mrs [name redacted]. Despite that a GP immediately before her death in a telephone consultation prescribed her with 100 tramadol tablets whilst recording that she needed an urgent review. The rationale for prescribing this volume of medication was unclear from the notes”

“There was a lack of continuity of care. Mrs [name redacted] saw a variety of different locum GPs. This meant that no clinician had an overview of her and her health. As a result, painkillers were repeatedly prescribed and other potential ways of managing her persistent back pain were not explored. This led to a significant reliance by Mrs [name redacted] on painkillers to manage her on going back problems”

“the lack of continuity of care was due to a national shortage of GPs and was a national not local issue”