Peter Stojilkovic

14 Mar 2018 · Coroner Alison Mutch · Manchester (South)

The coroner's concerns

1. prescribing melatonin in community
“The deceased had been prescribed melatonin whilst an in-patient”
2. use of blacklisted medication
“Whilst an in-patient the deceased was prescribed a drug melatonin that was on the Stockport CCG blacklist although not on all GM CCG blacklists”
3. complex prescribing guidance
“The inquest heard that GPs are faced with a mixture of lists regarding prescribing”
4. unlicensed internet sourcing of medication
“The deceased was told he would have to source melatonin for himself over the internet if his GP would not prescribe it”
5. lack of discharge communication
“It was known whilst he was an in-patient that difficulties with prescribing melatonin in the community would arise”

Responses

2018-0077-Response-by-NHS-England.pdf ↗· Pennine Care NHS Trust

Stated action

“we will raise the issue of how the provision of medication at discharge was handled by Pennine Care, and again identify any improvements that they need to make.”