Please note: This article was updated on December 5 to reflect a clarification that Billings received his second prescription from Lloydspharmacy, not Superdrug, as previously reported due to an error in the coroner’s report.
Coroner Luisa Maria Nicholson shared concerns around the death of 22-year-old Oliver James Billings, who died by suicide after a “prescribing error” left him “suddenly in possession” of hundreds of prescription drugs, in a prevention of future deaths report published this week (December 2).
The assistant coroner for Devon, Plymouth and Torbay said that Billings “was found deceased at his home address on December 6 2023” having consumed hundreds of prescribed tablets.
Nicholson added that it appeared Billings had “hoarded some of his medication” and acquired additional tablets “on or around November 29 2023 due to a prescribing error where he changed his choice of chemist from an online pharmacy – Pharmacy2U – to a local [Lloydspharmacy] store”.
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His GP surgery “sent an electronic request to Pharmacy2U to cancel the prescription and then issued the second to [Lloydspharmacy]”, she said.
“However, Pharmacy2U had already ‘pulled down’ the prescription before it was cancelled” and the pharmacy dispatched the prescription on November 28, she added.
“This meant that Billings was still able to collect the second prescription…from [Lloydspharmacy] and was suddenly in possession” of hundreds of tablets, she added.
“Aware of his own impulsiveness”
“The surgery sent Billings a text message asking him to contact Pharmacy2U to ‘return the prescription to the spine’ that presumably he chose to ignore,” Nicholson said.
“He had a long-established history of issues with his mental health including anxiety, depression, self-harm and previous suicidal ideation – he was also aware of his own impulsiveness,” she added.
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“A note was found by a police officer attending Billings’ flat on the day he died that stated that he did not have control over his medication and would take them all if left unsupervised,” the report said.
“This is sadly what appears to have happened,” it added.
P2U “could not be contacted”
Nicholson’s report listed several “matters of concern” raised by the inquest.
She flagged that “the swift dispatch of medication – while admittedly necessary in many circumstances – does not allow for mistakes to be noticed and/or remedied”.
And she warned that “the onus was on Billings to remedy the error when Pharmacy2U could not be contacted”.
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She added that “steps do not appear to have been taken or be able to be taken” to check whether the first prescription had been pulled from the spine before the second prescription was issued.
Nicholson sent her report to the GP surgery, Royal Pharmaceutical Society (RPS) and Pharmacy2U.
“In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action,” she said.
“Very sad”
A spokesperson for Clare House Surgery in Tiverton said that the practice was “very sad about the death of one of our patients and our thoughts go out to Oliver’s family”.
“We have received the report and will review it carefully as a team,” they added.
“We will determine what learning there is for us and any further changes or actions needed to take place as a result,” they said.
Read more: Coroner: Medicines regulator must ‘take action’ after anti-nausea P-med death
The spokesperson said that Clare House will respond to the final coroner report in January with the details of its learning and changes that it has made.
C+D also contacted the RPS, while Pharmacy2U declined to comment.
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