Pauline Meredith

10 Jan 2014 · Coroner Margaret Jones · Staffordshire South

The coroner's concerns

1. excessive medication without review
“The amount of medication prescribed to the deceased over many years with no formal medication review process”
2. addition of morphine to high-dose painkiller patient with alcohol dependence
“The more recent addition of morphine to the prescription for a patient already on a high dose of pain killers and with alcohol dependence”
3. GP ignoring family concerns about patient behaviour
“The family's perceived reluctance by the GP to listen to the concerns expressed by them with regards to the changed behaviour of the patient following the addition of morphine”
4. absence of multidisciplinary discussion of complex cases
“The lack of any team meetings with colleagues affording an opportunity to discuss challenging patients with colleagues”
5. delayed involvement of mental health services
“The lack of a more timely proactive approach with regards to involving community mental health services”