Elizabeth Dudley-Jones represented a national community pharmacy at inquest involving an inadvertent drug error. Mrs A, an elderly patient, was accidentally given a Nomad pre-filled drug tray meant for another patient. After taking the wrong medication for two days, Mrs A was admitted to hospital and later died. No post mortem was ordered. The Senior Coroner concluded the inquest with a narrative conclusion and he made no prevention of future death reports against the Company.