Forty-one-year-old Claire Copeland had a history of heroin use, senior coroner for the area of Durham and Darlington Jeremy Chipperfield wrote in his report, published earlier this month (March 8).

Her death was drug related, after she consumed drugs “including heroin” around June 17, “following a break in the continuity of her treatment for drug addiction”, he added.

Ms Copeland was unable to access her medicine following a “failed delivery of prescription” to the Boots pharmacy in Consett, County Durham, the coroner wrote.

A spokesperson for the multiple told C+D today (March 18) that Boots was “very sad to learn of the tragic death of Claire Copeland”.

The multiple has launched its own internal investigation into “the unique circumstances of this case”, the results of which have been shared with the coroner, it said.

Boots “will also share [its] feedback on [the coroner’s] assessment and recommendations”, it told C+D.

“Our thoughts are with her family and loved ones at this time,” the spokesperson said.

 

The events that preceded Ms Copeland’s death

 

Ms Copeland was released from prison – where she had begun opiate substitution therapy – on June 11 last year.

She received an initial dose of her medication upon her release and was scheduled to pick up more doses at the Boots pharmacy in Consett.

Substance support charity Humankind – which provided Ms Copeland’s treatment – “communicated with an employee at Boots to arrange delivery of the necessary prescriptions covering the weekend” following her release, according to the report.

The current procedure between Humankind and Boots “involves delivery of a physical prescription document”, the coroner found. A charity agent attempted to deliver Ms Copeland’s prescription in paper form to the pharmacy after it had closed and placed it in a letter box near the shopfront that did not belong to Boots, the report said.

“No attempt” was then “made to confirm effective delivery” although “the missing prescription was noted by Boots’ pharmacist” when Ms Copeland visited the branch to pick up the prescription the next day, the report said. It was a Saturday and she was unable to receive another prescription for the duration of the weekend because Humankind was closed.

 

Continuity of care not "fail-safe"

 

Mr Chipperfield concluded his inquest into her death on March 4 this year.

“The agreed system contained no fail-safe provisions ensuring continuity of care in the event of failed delivery of prescription,” he wrote.

One of the system’s flaws was its reliance on the delivery of a physical prescription document, Mr Chipperfield said, and the fact that deliveries did not need to be witnessed or confirmed.

He further criticised the “lack [of an] effective mechanism immediately to detect failed delivery” and to then “remedy” it.

These arrangements between the pharmacy and the charity Humankind “present[ed] danger to life in that it [was] capable of causing discontinuity of important medical treatment”, Mr Chipperfield determined.

 

Humankind “committed” to addressing coroner’s points

 

The coroner called on the manager of the Boots branch and the charity’s director to take suitable actions to prevent further deaths, placing them under duty to respond by May 3.

He also forwarded the report to Boots CEO Sebastian James and Humankind CEO Paul Townsley.

Humankind told C+D it was “fully committed to responding to the points raised in the coroner’s report within the required timescale”.

“We were saddened to learn of Claire Copeland’s tragic death last year and would like to express our deepest sympathies to Claire’s family and friends,” a spokesperson for the charity said.

Community Pharmacy Patient Safety Group (CPPSG) chair Victoria Steele told C+D that the report highlighted “the importance of good communication between different parts of the healthcare system”.

The CPPSG will discuss Ms Copeland’s “extremely sad case”, she said, “to consider what lessons can be learnt and actions implemented”.