Berkshire coroner Peter Bedford said that the effects of the mistaken overdose of propranolol "were likely to have been so minimal at the time of [Mrs Sheller's] death as to be able to be discounted as having any material effect". He said her death was "on the balance of probabilities" from "exacerbation of her underlying natural disease".

Although the coroner cleared Mrs Lee from contributing to Mrs Sheller's death he criticised medicines management procedures and has made recommendations to the Department of Health and the Royal Pharmaceutical Society about changes to dispensing procedures.

Mr Bedford told the inquest that all dispensed medicines should be double-checked before leaving the pharmacy and patients should be given a "clear written note of medication they are prescribed".

He told the inquest: "At the moment they hand in their prescription the public need to be educated on the requirement to double-check that their medication is correct by looking at the label on the box."

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