But it said the risk assessment carried out was poor, there was poor monitoring of MacLean's medicationcompliance and the trust's internal review of the incident was flawed.
Jaffe posits that the drop in A1c and LDL levels was not only due to a readjustment in dosage or a switch in medication, but also possibly to better compliance to existing medication in patients with the most elevated levels.
Other safeguards being proposed include guarantees about the storage and transportation of lethal medication, the reporting of assisted deaths and the powers for cases of non-compliance to be investigated.