Coroner Graeme Irvine expressed concern over the care provided to Chloe Every, highlighting significant lapses and the risk of future deaths unless immediate action is taken.
The inquest revealed that Chloe Every experienced a first cardiac arrest following a morphine prescription, which posed significant risks due to her pre-existing muscle-wasting condition.
Failures in Chloe Every's treatment included a lack of specialist assistance for her learning difficulties and procedural lapses, such as administering an enema without her consent.
Irvine noted the absence of important medical records severely hindered the investigation, preventing accountability and clarity regarding the treatment decisions made during her care.
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