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Poor discharge form caused GP's fatal error

Poorly completed hospital discharge forms have been blamed for a GP's error that led to the death of a 96-year-old woman.

Dr Simon Purnell, a GP in Ilkeston, Notts, authorised five repeat prescriptions of digoxin, which a consultant had prescribed at four times the recommended dose, an inquest heard.

His patient, Elsie Fletcher, died from poisoning by digoxin, which was prescribed for an arrhythmia heartbeat. The inquest was told discharge notes made no mention of the drugs she had been given or her heart condition.

Dr Purnell told the inquest he only realised the mistake on the day of Mrs Fletcher's death.

'I think our system should have picked it up and I take responsibility for that,' he said.

Coroner Peter Ashworth said he would ask the trust, the Queen's Medical Centre, to ensure drugs like digoxin

were flagged up on discharge forms.

Nottingham LMC's chief executive Chris Lock said poor discharge notes were a longstanding problem.

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