One of my patients – let’s call her Pauline – was a lovely lady in her 50s with mild learning disabilities, chronic alcoholism, and a schizoaffective disorder that meant her drugs were dispensed into an automatic discus-shaped monitored dosage system (MDS).

At set times this battery-powered device sounds an alarm, flashes a light, and rotates a tray so the dose can be tipped out. Bemused and anxious in equal measure, Pauline referred to her device as “Star Trek”. For years, it allowed her to boldly go where she had not gone before until one week when she didn’t pick up her prescription and we were told, somewhat awkwardly by her GP surgery, that she had died.

That was all the information we had until a year later came a phone call from the coroner’s assistant who opened with “GDPR requirements don’t apply to the dead, so you can give me all your information about this patient”.

The pharmacy technician who took the call was, however, schooled in our strict confidentiality procedure and declined to give out any information.

“I suggest you speak to the pharmacy superintendent,” I heard her say with such an ominous look and tone that I feared for what might be about to hit the fan. I was relieved when just a contact email address was requested.

The phone had barely been put down before a few staff members began speculating: “I told you it was strange.” “Why has it taken this long?” “What do they want from us?”

What they wanted from us was a formal report to the coroner with full patient medical records (PMR), and a list of specific points to address. This included a statement describing how the MDS device works, the dispensing process in detail, and what checking procedure was in place. Finally, in case we were in any doubt about the reason for these questions, it said: “Cause of death: acute toxicity of citalopram.”

At this point, the cold reality of consequences came home. Everyone tried to remember and reassess actions and procedures that a year ago had seemed everyday. Along with many other drugs, Pauline was on 40mg of citalopram, so we couldn’t have made a dispensing error of too high a dose – but could we have dispensed two doses in error?

A Google search revealed an article about responding to coroners that advised to be factual, clear, precise and prompt. However, to do so took me a whole day of gathering and retrieving PMR data and other documents requested.

The report was sent off, its promptness receiving a grateful acknowledgement but no suggestion of further process. We are still waiting. Much to the disappointment of the staff, we are unlikely to be informed of the outcome, so we just wait to see if I am called to give evidence in person.

Whatever the outcome, it was indeed a salutary lesson about the importance of evidence keeping and another reminder of the seriousness of what can seem the most routine dispensing task.

A long-running C+D contributor, the identity of Xrayser remains a mystery, but his irreverent views are known by all. Tweet him @Xrayser