Tramadol overdose death raises questions over repeat prescriptions

Geoffrey Sullivan, a senior coroner in Hertfordshire has written to the Chief Executive of NHS England Simon Stevens to express concern after the death of Mr Peter Cole.

On August 14th 2019 Mr Cole was found by his neighbour collapsed at home. Despite attempts by the emergency services to resuscitate him he, unfortunately, passed away later that day.

The causes of death listed on the post mortem were drug overdose and also ischaemic heart disease. The conclusion of the subsequent inquest was that Mr Cole’s death was prescription drug-related.

Mr Cole suffered from dementia and it was noted that he was regularly in receipt of multiple repeat prescription medicines. One of the medicines that he was receiving regularly was tramadol. He received 100 tramadol capsules per month.

This was the drug that Mr Cole overdosed on.

Mr Sullivan did not find probable contribution to Mr Cole’s death from the other medicines that were found to be in excess in his house.

An experienced mental health nurse gave evidence to the coroner and she indicated that this level of excess repeat prescription medication was not unusual. She said that she would often find large quantities of repeat prescription medicines and medical devices and that the control of supply was not always properly supervised. These patients would invariably have a level of mental impairment. She said that she would on occasion find ‘cupboards full’ of prescription medicines in peoples’ houses.

Mr Sullivan judged that there was a risk of future deaths and raised several issues as a matter of concern.

He indicated that repeat prescription medicines are not well enough monitored or supervised and therefore many people who are older or mentally ill may accumulate dangerous levels of these medicines.

He also asserted that the inadequate supervision of repeat prescribed medication was so widespread that the resultant waste of resources had a detrimental effect on the delivery of healthcare.

Mr Sullivan wrote to Simon Stevens to express his concern due to the risk of future deaths.

You can read the full coroner’s report here.

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