Date of prep: December 2020
Prescribing information and
adverse events reporting
For healthcare professionals only
On 13th February 2020, James Edward Thompson Assistant Coroner, for the coroner area of County Durham & Darlington commenced an investigation into the death of Laura Eve Parsons, 36.
The investigation concluded at the end of the inquest on 1st September 2020. The conclusion of the inquest was a narrative which found the deceased Laura Eve Parsons died on 5th November 2019 after consuming an excessive quantity of morphine which was prescribed to her, it’s toxicity ultimately causing her death.
On 5th November 2019 police became aware of concerns for the deceased and entry was forced to her home address where she was found dead. An empty 500ml bottle of liquid morphine was recovered from a waste bin inside the address. A subsequent post mortem and toxicological examination revealed fatal levels of morphine in the deceased at the time of her death.
James Edward Thompson Assistant Coroner, for the coroner area of County Durham & Darlington, commented:
“During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken.
“Ms Parsons was prescribed liquid morphine to treat ‘breakthrough’ pain for cancer. It was first prescribed on 9th August 2019. Ms Parsons was admitted to hospital on 10th August 2019 with an accidental overdose of morphine. It appears 180mls were consumed in a 12 hour period. She recovered and was discharged from the hospital. The remainder of the prescribed morphine was discarded.
“On 31st October 2019, Ms Parsons requested a repeat prescription of liquid morphine from her GP surgery. This was authorised and a 500ml bottle of liquid morphine was dispensed to Ms Parsons. On 5th November 2019 Ms Parsons was found dead due to ingesting a fatal amount of morphine.
“At inquest evidence was given that information such as recent overdose would be added to the ‘Active Problems’ section on a person’s medical records and would be prominent when any clinician accessed that person’s records.
“It was explained at the inquest that when a patient applies for a repeat prescription so far as the request is within the permitted timescale to issue a repeat of the prescribed item, then the prescription would be issued without any further scrutiny and the electronic systems would not take a prescriber to the patient’s medical records and in particular the ‘Active Problems’ section.”
The Coroner has raised these concerns with the relevant organisations and authorities.
We are welcoming letters to the editor. Feel free to get in touch using the form below.
This article is being shared under the Open Government Copyright licence.
Pharmacy in Practice is a UK pharmacy publication with its roots in Scotland.