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Derrick Twiate

Ref: 2016-0079 Date: 29 Feb 2016 Coroner: Murray Spittal Area: South Lincolnshire 0 responses identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner noted that pharmacists in general practices continue to snip tablets from unit dose packs into multi-dose compliance aids, a practice contrary to professional body advice.

Date 29 Feb 2016
56-day deadline 25 Apr 2016 est. estimated from the report date
Responses identified 0 of 2
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The coroner noted that pharmacists in general practices continue to snip tablets from unit dose packs into multi-dose compliance aids, a practice contrary to professional body advice.
View full coroner's concerns
_ That although this practice of snipping tablets from the unit dose packs, still in their bubble, and place them in the compartments of multi-dose compliance aids is contrary to the advice of the relevant professional bodies, it apparently still done by dispensing pharmacists dispensing general practices_

Report sections

Investigation and inquest
On 26th November 2015 commenced an investigation into the death of Derrick TWAITE, age 86_ The investigation has not concluded, but evidence has been disclosed that indicates a situation exists that should be brought to the attention of relevant practitioners.
Circumstances of the death
1) Mr Twaite had his medicines dispensed in a multi compartment compliance aid. One of his medicines was Finasteride, which is presented in a multi tablet bubble pack Finasteride tablets, in their bubble where snipped from the multi-dose pack and placed in the compartments of the compliance aid. Mr Twaite appears to have swallowed one Finasteride tablet, still in its sharp edged bubble Unit 1 , Gilbert Drivve, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk

A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire pack segment: This caused a gut perforation which led to his death.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have the power to take such action.
Copies sent to
1) Lincolnshire Police2) Inspector C.Q.C_3) Prescribing Advisor, Arden and Greater East Midlands Unit 1 , Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire gov.uk being and duty 28th

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Report details

Reference
2016-0079
Date of report
29 February 2016
Coroner
Murray Spittal
Coroner area
South Lincolnshire

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 25 Apr 2016 (estimated from the report date).

Sent to

Dispensing Doctors Association
Royal Pharmaceutical Society

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.