Jerome Peat

PFD Report Historic (No Identified Response) Ref: 2021-0031
Date of Report 8 February 2021
Coroner Dr Simon Fox QC
Coroner Area Avon
Response Deadline ✓ from report 6 April 2021
Alcohol, drug and medication related deaths Community health care and emergency services related deaths Other related deaths
Judiciary.uk Report PDF
Coroner's Concerns (AI summary)
A computer system failure at the GP surgery led to duplicated morphine prescriptions, causing the deceased to receive significantly more medication than intended and resulting in an overdose.
View full coroner's concerns
The EMIS computer medical record on 4.11.19 failed to alert] at Long Furlong Medical Centre that Mr. Peat had already registered with the GP at the Student Medical Centre, as a result of which there was inadvertent duplication of his morphine prescription on 4.11.19 and 5.11.19 and Mr: Peat was prescribed significantly more morphine than was intended. subsequently died from an overdose of Telephone 01275 461920 Email AvonCoronersTeam@bristol gcsxgov:uk Website wwwavon-coroner.com The Coroner'$ Court; Old Weston Road, Flax Bourton, BS48 1UL He prescribed morphine
Sent To
  • Long Furlong Medical Centre
Response Status
Linked responses 0 of 1
56-Day Deadline 6 Apr 2021
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On 04/03/2020 an investigation was commenced into the death of Jerome Alexander Peat: The investigation concluded at the end of the inquest on 03/02/2021. The conclusion of the inquest was that the death was "Drug Related" and found that Mr: Peat died from an overdose of prescribed medication; including morphine:
Circumstances of the Death
Mr: Peat was prescribed morphine by Long Furlong Medical Centre on 4.11.19,by the Student Medical Centre in Bristol on 5.11.19 + 21.11.19 and by the out of hours doctor in Bristol on 1.12.19. He was found dead from an overdose of morphine on 12.12.19 at his student accommodation.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe vou have the power to take such action:
Copies Sent To
coroner.com The Coroner's Court; Old Weston Road, Flax Bourton, BS48 1UL and QC, Fox
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.