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recurance

Tracey Oldfield

11 Nov 2025 · Coroner Andrew Cox · Cornwall and the Isles of Scilly

This report repeats 1 earlier warning. See the linked reports.

The coroner's concerns

  1. 1. delayed prescription of usual medication

    “need for patients who are admitted late and unexpectedly (of which the PSII recorded there are over 1,000 annually) to have their usual medication prescribed in timely fashion. On”

Linked reports

Repeats an earlier warningRaymond Woodhouse21 Oct 2020 · 5 years 1 month earlier
Closely relatedConfidence 0.80 · moderate

Earlier report

“'multiple' occasions when medication was given late and three occasions when it was not given at all”
Original on judiciary.uk ↗

This report

“need for patients who are admitted late and unexpectedly (of which the PSII recorded there are over 1,000 annually) to have their usual medication prescribed in timely fashion.”
Full chain: Inconsistent medication administration timing

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.

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