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recurance

Teresa Bennett

14 Feb 2024 · Coroner Sarah Riley · North West Wales

The coroner's concerns

  1. 1. lack of medication review compliance

    “Lack of compliance with the target of 12-15 monthly medication reviews in Health Board managed GP practices”
  2. 2. absence of standard medication review practice

    “No standard practice for medication reviews leading to a lack assurance that all pertinent matters will be covered and the approach varying between clinicians and practices”
  3. 3. inadvertent overdose risk

    “The risk of inadvertent overdose in individuals like Ms [name redacted], where medication that can cause e.g drowsiness and fatigue, is prescribed alongside strong opiates and other drugs that have the ability to depress the central nervous system when such medicines are prescribed without regular reviews nor specific advice in respect of the associated risks issued to patients e.g in Ms [name redacted] case, she was instructed to simply”

Responses

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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.

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