Coroner: Patient died from overdose after GP pharmacist ignored warning
A coroner has raised concerns about GP practice “safety measures” after advice from a dispensing pharmacist and consultant psychiatrist was ignored.
Recommendations to “limit the amount of prescription medication available” to a patient were ignored by a practice pharmacist before the patients’ death, coroner Sarah Huntbach found.
In a prevention of future deaths report published last month (June 28), Huntbach said that 55-year-old Debra Bates, who suffered “with her mental health and chronic pain” for “many years”, had “a chaotic prescription pill use”.
Huntbach said that after Bates was admitted to hospital following an overdose that caused “opiate toxicity”, a consultant psychiatrist recommended that her weekly prescription “be changed to four-day and three-day prescriptions to minimise the risk of overdose” in April 2023.
“The dispensing pharmacist said that non blister pack three- and four-day prescription [could] be facilitated” and “post-dated to be collected on Tuesdays and Fridays for example”, she added.
But “this did not happen”, she said.
“Medication above therapeutic levels”
“A task was sent to the practice pharmacist to discuss the case” but they said that more frequent prescriptions “could cause confusion as double items would need to be added to the repeat prescription for each duration”, the report added.
“This would result in more frequent deliveries and could cause issues” such as a “risk of overprescribing”, it said.
Instead, Bates “continued to be prescribed her medication at seven-day intervals plus breakthrough pain medication as required”, the report added.
On June 15 2023, Bates was “found dead at home” and “post mortem toxicology found prescribed medication at above therapeutic levels in her blood”, Huntbach said.
She added that “on the evidence”, Bates had “taken a mixture of prescribed medication in quantities that have had an enhanced sedative and respiratory depressant effect leading to her death”.
Coroner concerns
“While limiting the amount of medication prescribed to Bates at regular intervals would have reduced the amount she had access to at any one time, it cannot be established on the evidence that it would have prevented the overdose and her death,” Huntbach said.
But she added that the investigation had given “rise to concern” and that there was “a risk that future deaths could occur unless action is taken” by the GP surgery.
“No further investigation or inquiries were made as to how other practices implemented this prescribing approach in a case where there are multiple medications - including controlled drugs,” she said.
Neither were there investigations into “whether [or] what safety measures are available on the computer system to prevent [or] minimise the risk of the wrong prescription being requested,” she added.
NHS Derby and Derbyshire integrated care board (ICB), which was also sent a copy of the report, today (July 17) said that it “strives to improve provider adherence to good practice guidance and recommendations around the prescribing, handling and supply of controlled drugs consistently in all healthcare settings”.
It added that it “is aware of the prevention of future deaths report and will respond in full in line with the coroner's request”.
Meanwhile last month, a coroner found that regulatory “gaps” left a patient unprotected from companies selling “huge” quantities of “powerful drugs” online.
“Elite” army veteran Nigel Dixon, who had a history of “physical and mental health issues” including depression, suicide attempts, chronic alcohol misuse and opioid dependence, was found dead in his home on February 13 2023 due to “Morphine and Zopiclone toxicity”.
Dixons’ family provided “documentary evidence of him purchasing drugs online before he died”, while a GP giving evidence at the inquest deemed the amount he was able to purchase “huge”, according to a report.
“There seems therefore to be a situation where one could purchase almost limitless amounts of these drugs with no checks or balances at all,” the coroner warned.
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