"The provision to Ms. MITCHELL of 28 days’ worth of prescribed medication in less than a 48-hour period (14 days’ worth of medication dispensed on each occasion she was discharged hospital on the 3rd and 4th of August 2022). This occurred at a time when, due to concerns about Ms. MITCHELL hoarding medication and taking an overdose, she was receiving weekly medication prescriptions from her GP to control this risk.

"The evidence heard at Inquest indicated that there was no process in place whereby accident and emergency staff could access Ms. MITCHELL’s medical records detailing the medication she was receiving and the rationale behind the dispensing regime in place."