Skip to content
recurance

Michael Tarratt

14 Mar 2014 · Coroner Lydia Brown · Leicester City & South Leicestershire

The coroner's concerns

  1. 1. lack of regular contact between treatment services

    “Despite Evidence from the Drug and Alcohol team that it was appropriate to update the relevant GP every 3 months, or at least every 6 months, it was accepted on this occasion that no contact had been made for 18 months. Consideration should be given to more regular contact between the services providing treatment.”
  2. 2. inappropriate tramadol prescription for opiate dependent patient

    “Despite Evidence that the GP prescription of tramadol (for knee pain) was inappropriate for an opiate dependent patient, no contact was made with the GP surgery 1”

Responses

2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust.pdf ↗· Leicestershire Partnership NHS Trust

Stated action · 2 May 2014

“A notification by way of urgent memo by email has been sent to all members of the Drug & Alcohol team that the agreed standard for communication and correspondence with patients' GPs is that contact must be made with the GP: ¢ After the initial assessment;”
  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error