Kathleen Neville
7 Aug 2015 · Coroner Christopher Woolley · Cardiff and the Vale of Glamorgan
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of medication reconciliation policy
“The absence of a Medication Reconciliation Policy at the University Hospital of Wales over the relevant period made it much harder for the individual failures of the admitting doctor and initial pharmacist to be picked up. As a consequence [the deceased] was deprived of her medication for a much longer period than would otherwise have been the case.”
2. absence of medication reconciliation policy in other health boards
“The Coroner is concerned that there may be other Health Boards across Wales that have still not adopted a Medication Reconciliation Policy as recommended by NICE. Future lives may be lost if a Health Board does not have such a policy and similar prescription errors are made. The Coroner is concerned that all Health Boards across Wales should learn the lessons of this inquest and have a Medication Reconciliation Policy in place to prevent future deaths in similar circumstances.”
3. omission of critical medication causing death
“the Coroner found in this inquest that the omission of Levothyroxine did not contribute to the eventual outcome, the position would have been far different in the case of other drugs where omission of medication might well lead directly to death (e.g. insulin). In such cases the absence of a Medication Reconciliation Policy to assist in picking up individual failures could well lead to future deaths.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“The absence of a Medication Reconciliation Policy at the University Hospital of Wales over the relevant period made it much harder for the individual failures of the admitting doctor and initial pharmacist to be picked up.”
Later report
“The Health Care Professional did not have access to detainee's medical records to accurately identify reasons as to why and how medications are changed or as to when this may or may not have occurred.”
Responses
No published response was found on judiciary.uk.