Kathleen Neville

The MIATTERS OF CONCERN are as follows (1) The absence of a Medication Reconciliation at the University Hospital of Wales over the relevant period made it much harder for the individual failures of the admitting doctor and initial pharmacist to be picked up. As a consequence Kathleen Neville was deprived of her medication for a much longer period than would otherwise the Policy have been the case_ (2) While the Coroner found in this inquest that the omission of Levothyroxine did not contribute to the eventual outcome, position would have been far different in the case of other drugs where omission of medication might well lead directly to death (e.g: insulin) . In such cases the absence f a Medication Reconciliation Policy to assist in picking up individual failures could well lead to future deaths_ The Coroner found that any system that relies solely on individual human excellence without a supporting policy is eventually bound to fail through individual human error.

(3) The Cardiff & Vale University Health Board has now introduced a Medication Reconciliation as recommended by the NICE Guidelines (now updated): The Coroner was satisfied that this was chiefly because of the death of Kathleen Neville The Coroner was satisfied that University Hospital of Wales and the Cardiff & Vale University Health Board have taken appropriate remedial action: (4) The Coroner is concerned that there may be other Health Boards across Wales that have still not adopted a Medication Reconciliation Policy as recommended by NICE_ Future lives may be lost if a Health Board does not have such a policy and similar prescription errors are made: The Coroner is concerned that all Health Boards across Wales should learn the lessons of this inquest and have a Medication Reconciliation Policy in place to prevent future deaths in similar circumstances