A 78-year-old has overdosed after being given excess diazepam and codeine ahead of the long Easter bank holiday weekend earlier this year, a coroner’s report this week (November 25) revealed.
Senior coroner for Derby and Derbyshire Peter Nieto said that Margaret Feeney “died due to taking excess prescribed medication that she had become dependent on and addicted to”.
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“She had access to excess medication because of medical prescribing decisions and arrangements leading up to a bank holiday period,” he added.
Nieto raised concerns that measures to prevent excess prescribing ahead of single bank holidays when pharmacies are closed had not been replicated for longer bank holidays.
“Recognised to overuse”
Feeney had been prescribed benzodiazepines and codeine for a long time, with codeine prescribed for pain conditions, the report said.
It added that she had become dependent on the medicines and was “recognised to overuse them” so was given seven-day prescriptions.
One of Feeney’s friends was “concerned that [she] was confused” and both attended a GP appointment the week before her death, it said.
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While the GP reduced Feeney’s diazepam prescription and issued a “lower dose in a daily dose blister pack”, her codeine prescription was not altered, it added.
During that week, Feeney received her prescriptions on three separate occasions – leaving her with “an excess of five days” of diazepam and “four days excess codeine” ahead of the bank holiday, the coroner found.
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She was found dead at home on April 1 by a friend and cleaner with “empty or near empty blister packs” from her prescribed medication, according to the report.
The coroner said that there was “no reason to consider that Feeney had deliberately taken the excess medication to cause her own death”.
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But he added that there was a “real and foreseeable risk that [she] would take excess diazepam and codeine that was available to her between March 27 and her death” due to her “recognised dependence and overuse”.
Feeney’s post-mortem recorded the “medical cause of [her] death as the combined toxic effects of prescribed medication that she had taken in excess” as well as a high total morphine level in her body and pneumonia which “contributed to her death”, the report said.
“No measures” for long bank holidays
After a seven-month investigation that concluded this month, the coroner raised concerns that there are “no measures relating to longer bank holiday periods” such as Easter when early prescriptions are issued because pharmacies are “likely to be closed”.
He added that such measures are already in place to “prevent excess prescribing by taking account of single-day bank holidays” and that his concerns over longer bank holidays are “likely to apply to other GP practices and pharmacies”.
Nieto also warned that the GP surgery and pharmacy do not have “measures” in place to “prevent prescription of excess medication to patients recognised to be at risk of overdose, either intentional or unintentional, who are ordinarily issued shorter period repeat prescriptions to reduce those risks”.
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He sent the report to Macklin Street Surgery and Daynight Pharmacy - both in Derby - as well as to health secretary Wes Streeting and the NHS Derby and Derbyshire Integrated Care Board (ICB), who have until January 20 to respond.
C+D approached Daynight Pharmacy and Macklin Street Surgery for comment, but the GP practice declined to provide a statement.
If you have been affected by any of the issues in this article, you can contact Pharmacist Support by emailing info@pharmacistsupport.org or calling 0808 168 2233/0808 168 5133 for free