Source · Prevention of Future Deaths

June Rose

Ref: 2014-0267 Date: 11 Jun 2014 Coroner: Lorna Tagliavini Area: London (West) Responses identified: 0 / 1 View PDF

A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous prescription, contributing to the patient's death through respiratory depression.

Date 11 Jun 2014
56-day deadline 6 Aug 2014 est.
Responses identified 0 of 1
Community health care and emergency services related deaths

Coroner's concerns

AI summary
A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous prescription, contributing to the patient's death through respiratory depression.
View full coroner's concerns
no mandatory training or regular refresher training on national level in the prescribing of these kinds of drugs_ Therefore , require to be informed as to what steps are, or will be made available or required to all GPs to familiarise themselves with the prescription of these types of pain relief medications in order to prevent a potentially and directly fatal error from occurring In accordance with a copy of this report is sent to the Chief Coroner as well as all the other properly interested persons identified at the inquest: A list of the copy recipients can be found at the end of his report Your response to the report will also be shared with those listed , The Chief Coroner may send copy of the report and response to person who he believes may find it useful or of interest_ In addition the Chief Coroner may publish a full copy or summary of the report and response (unless there are approaches made in respect of non-publication) The rules require that you provide a written response within 56 days of the the report is sent: If you are unable to respond within that time, you may apply to me for an extension: The response is to contain details of any action that has been taken or which is proposed will be taken whether in response to this report or otherwise, or an explanation as to why no action is proposed_ If there are circumstances where you do not want your full response to be shared with the copy recipients listed at the end of his report, or for a copy of it to be published, you may make written representation to me at the time giving your response. instead of releasing or publishing your full response it may be possible to share or publish a summary in accordance with rule 43A. look forward to receiving your response. Yours sincerely, Lrh Taphsiiv = Lorna Tagliavini, Assistant Coroner, West London cC; The Chief Coroner at The Mound Medical Centre daughter) & family members being any day

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Report details

Reference
2014-0267
Date of report
11 June 2014
Coroner
Lorna Tagliavini
Coroner area
London (West)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 6 Aug 2014 (estimated).

Sent to

Royal College of General Practitioners

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