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John James

11 Jul 2023 · Coroner Nadia Persaud · East London
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The coroner's concerns

  1. 1. failure to monitor medication administration

    “The refusal of anti-coagulation medication was not brought to the attention of medical staff”

Responses

2023-0242-Response-from-Bart-Health-NHS-Trust-1.pdf ↗· Barts Health NHS Trust

Stated action

“The electronic prescribing and medicines administration system (ePMA) currently has functionality (all of which is accessible via Millennium®) to reduce harm associated with missed or late medication administration. This includes visual aids in the form of a red tile if a dose is delayed by more than 2 hours. This visual flag is available to all users. Millenium training will be updated to reflect learning from this case to ensure that multi-professional teams know how to use the flag system to”
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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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