Coroner: Patient dies after pharmacy supplied 'additional methadone’
A man has fatally overdosed after his pharmacist misinterpreted the wording of his prescription and gave him medicine “in advance” even though the pharmacy was open, a coroner has found.
“The actions of [a] pharmacy contributed more than minimally” to the death of 45-year-old Anthony Paul Nixon by “supplying additional methadone on multiple occasions”, a prevention of future deaths report published yesterday (August 19) has warned.
Nixon “was found deceased on June 12 2023 at his home address…as a result of a drug overdose”, Durham and Darlington assistant coroner Janine Richards found during an investigation that ended last week (August 15).
She said that “on a number of occasions in the period leading to his death”, Nixon was given his medication “in advance for days when the pharmacy was open”.
She stressed that this was “not in accordance with the prescription that was issued for him”, which was for “supervised consumption…on specific days”.
“In possession of multiple doses”
“The pharmacist in this case gave evidence that he believed that he had a discretion to provide [the drug] in advance…and maintained this was a ‘standard practice’ when the pharmacy was open for half a day on Saturdays”, the coroner’s report said.
It added that he misinterpreted the prescription, which said “please dispense instalments due on a pharmacy closed day on a prior suitable date”.
It said that the pharmacist “interpreted the wording” to “include Saturdays when the pharmacy was open for half a day, despite the prescriptions stipulating the specific days that the [medicine] was to be provided, including specification of the dose each Saturday”.
“This led to a situation where the deceased was in possession of multiple doses of a controlled drug…on a regular basis in the period leading up to his death” despite the prescription being “carefully considered to attempt to manage the obvious risks”, it added.
It said that the pharmacy was “specifically chosen by the deceased’s drug treatment provider” because it could provide supervised administration “on a six day per week basis”.
In the drug treatment providers’ assessment, “this was required to attempt to manage the risks inherent in the deceased having access to multiple doses”, it added.
“Gravity of the situation”
“I was not reassured that the pharmacist fully appreciates the gravity of this situation”, Richards said.
“In evidence he continued to maintain that he could exercise a discretion in relation to the provision of [the] controlled drug,” she added.
And she reiterated that supplying it “not in accordance” with the prescription “was described as a standard practice” by the pharmacist.
“For the avoidance of doubt, the circumstances of this case have been alerted to the General Pharmaceutical Council (GPhC) as the appropriate regulator”, Richards added.
“But there has been no update received as to whether an investigation has been undertaken or any action recommended”, she revealed.
A spokesperson for the GPhC told C+D that it was “very sorry to hear about the death of Mr Nixon”.
They added that the regulator takes “any prevention of future deaths reports extremely seriously” and is “looking into concerns raised by the coroner” and “assessing whether improvements may be needed” at the pharmacy in light of the report.
C+D approached the pharmacy for comment.
The coroner also sent the “matters of concern” to the pharmacy, two drug and alcohol treatment agencies and to the Care Quality Commission (CQC) “who may find it useful or of interest”, the report revealed.
In June, C+D reported that a man was found dead after a pharmacy accuracy checking technician alerted police when he failed to collect his methadone prescription.
And in February, a coroner raised concerns that pharmacies have “no apparent obligation” to report when a patient stops collecting methadone, after a man died when a pharmacy’s warnings were ignored.
