John Day
4 Jun 2014 · Coroner Caroline Sumeray · Isle of Wight
The coroner's concerns
1. lack of access to medical records
“During the course of my investigation, I heard live evidence from who was the out-of-hours doctor who visited Mr [name redacted]. He told me that he did not have access to medical records and that this was a common situation. He said that he had asked Mr [name redacted] if he had any allergies to medication, and Mr [name redacted] replied that he did not have any such allergies. Whilst Mr [name redacted] appeared to have capacity, the information which he gave to was incorrect, and as a consequence, prescribed Co-Amoxiclav to Mr [name redacted].”
2. inability to verify medication appropriateness
“In this case, the patient did not die as a result of the medication which was prescribed, but if the patient had died, an inquest would have inevitably resulted. Moreover, the patient had capacity to give an (incorrect) answer, but if the patient lacked capacity to do so, I am concerned that the out-of-hours doctor has no way of verifying the appropriateness of the medication which he wishes to prescribe. Accordingly I am concerned that there is not a way in which out-of- hours doctors can access”