Martin Hill
22 Aug 2014 · Coroner Veronica Hamilton-Deeley · Brighton & Hove
The coroner's concerns
1. delayed antibiotic administration for infection
“Although this man arrived in A & E on the 28”
2. inadequate withdrawal management for opioid dependent patient
“Whilst it is noted that Mr. HILL was admitted at lunchtime on a Friday and the critical events took place over a weekend, nonetheless he was known to be an intravenous heroin user on a Methadone prescription and yet he was given no treatment for withdrawal treatment save for 2mg of Diazepam on the 28”
3. inadequate medication record review and oversight
“There are serious omissions on the Medical Administration Record. | was told that it was believed that no Senior Pharmacist reviewed the MAR charts over a weekend. Given the importance of medicating patients correctly, it would seem advisable that there should be a review, if indeed it is the practice that records are not reviewed. It seems that in this particular case the charts are particularly poorly written and perhaps those involved with this patient would benefit from a discussion with the”