Edna Cleaton
PFD Report
Historic (No Identified Response)
Coroner's Concerns (AI summary)
The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in review and a missed opportunity to identify deterioration.
View full coroner's concerns
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. (1) The evidence heard at the inquest was that patients on citalopram should be reviewed by a doctor every 3 – 6 months. This lady had not been reviewed for over 3 years. The practice need systems in place to ensure patients received appropriate medical reviews before repeat prescriptions are issued. Had regular reviews been undertaken it is possible that medical staff would have identified deterioration in the deceased and a care plan could have been instigated which may have avoided the pressure sores that developed.
Sent To
- Jockey Road Medical Centre
Response Status
Linked responses
0 of 1
56-Day Deadline
11 Feb 2016
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 21/10/2015 I commenced an investigation into the death of Edna May CLEATON DOB 30/08/1914, aged 101. The investigation concluded at the end of the inquest 16th December 2015. The conclusion of the inquest was that the deceased died from sepsis caused by sacral and leg pressure sores.
Circumstances of the Death
The deceased died at her home address on 11/10/15. She had serious pressure sores which had become septic and caused her death. She had not been seen by a doctor for over 3 years despite being prescribed Citalopram for depression. The practice had been providing repeat prescriptions for this period.
Copies Sent To
I am also under a duty to send the Chief Coroner a copy of your response
Louise Hunt Senior Coroner Birmingham and Solihull
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.