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Coroners inquire into sudden, unexpected, or unnatural deaths. We have previously established 99 cases (100 deaths) in England and Wales in which medicines or part of the medication process or both were mentioned in coroners’ ‘Regulation 28 Reports to Prevent Future Deaths’ (coroners’ reports). We wished to see what responses were made by National Health Service (NHS) organizations and others to these 99 coroners’ reports.
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