Derrick Twiate
PFD Report
Historic (No Identified Response)
Ref: 2016-0079
No published response · Over 2 years old
Response Status
Responses
0 of 2
56-Day Deadline
25 Apr 2016
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroners 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_
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.
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.
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.
Copies Sent To
1) Lincolnshire Police
2) 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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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.