During the Inquest; evidence was heard that: 1_ Conflicting guidance is provided to treating clinicians as to when Vitamin D and Calcium blood level monitoring should be undertaken especially in patients who are given higher (loading) doses of Vitamin D, which exceeds the recommended national guidelines. The Consultant in Acute Adult Medicine gave evidence that he expected blood level monitoring to have taken place within 4 weeks of the loaded Vitamin D commencing; whereas the Endocrinologist, gave evidence that he expected blood level monitoring to take place around the 3 month period to ensure the course of medication had been completed: In any event, no advice or instructions were issued to the deceased GP, regarding any requirement to monitor the deceased blood levels whilst she was in the community and taking high levels of Vitamin D which exceeded national guidelines:
2. Irequest that The Chief Executive of The Royal Bolton Hospital reviews: The guidance and practices adopted by staff; in regard to when blood monitoring of the above types of patients should take place to ensure a consistent and safe approach is adopted: the being

3. The WellSky and EMIS Software, had a confusing user drop down menu option, which allowed the user to click on a twice daily dose despite the oaded dosage, exceeding national guidelines:
4. Irequest that The Chief Executives of WellSky and EMIS Software company reviews:
5. The dropdown user options to ensure better system safety nets are put in place to prevent catastrophic prescribing errors occurring in the future ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe that you have the power to take such action: YOUR RESPONSE You are under a duty to respond to this report within 56 of date of this report; namely by 24TH April 2020. I, the Coroner, may extend period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed: COPIES and PUBLICATION Ihave sent a copy of my report to the Chief Coroner ad to the following Interested Persons: - Son of deceased Iam also under a to send the Chief Coroner a cOpy of your response: The Chief Coroner may publish either or both in complete or redacted or summary form: He may send copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the Coroner, at time of your response, about release or the publication of your response by the Chief Coroner. Dated Sighed 28t February 2020 ukel kZhul %l Rachel Syed HM Assistant Coroner days the the duty the the