Lockdown methadone dispensing incident ‘directly contributed to death’


A young man who we will refer to as Mr MF was found deceased on the 17th April 2020 at his home address. Mr MF was known to have drug dependency issues and had been receiving support for this.


Mr MF was last seen by his family on the 15th April 2020 and he appeared fit, well and in good spirits. Toxicology analysis identified a toxic quantity of methadone in Mr MF’s blood at the time of his death.


Mr MF received his methadone prescription and prior to the Covid-19 pandemic lockdown, he was prescribed methadone three times per week in daily dosage bottles. Due to Covid-19 restrictions, his prescription was changed to once every 14 days. This meant Mr MF had a much larger quantity of methadone than he would normally have.


The methadone Mr MF was given by his pharmacy was also not in daily doses as prescribed. Despite the risk mitigation put in place, the coroner said that Mr MF’s access to increased quantities of methadone directly contributed to his death.


Although the level of methadone in Mr MF’s system was found to be much higher than the usual toxic level, the coroner said that there was no evidence to suggest that he intended to take his own life.


At the inquest the coroner made the following comments:


“During the evidence, it was heard that at the start of the Covid-19 pandemic Public Health England guidance was issued that individuals on opiate replacement treatment should be moved off short term (daily or tri-weekly) prescription collections to longer-term ones.


“In Mr MF’s case, his collection was changed from 3 times per week to fortnightly. The doctor who made the changes to the prescription stipulated that Mr MF’s dose must be in single daily dosage bottles. Mr MF had a secure store in his home and was used to taking his methadone from single daily dosage bottles.


“In addition, the doctor had sent a letter to all of the pharmacy’s that supplied opiate replacement therapies to his patients, explaining that only daily usage bottles should be prescribed.


“On the 15th April 2020, Mr MF collected his 14-day methadone supply from his community pharmacy.


“Evidence produced by Mr MF’s father during the inquest itself, clearly showed that Mr MF had been issued three bottles of Methadone to cover the 14-day period. These bottles contained 100ml, 156ml and 500ml of methadone respectively.


“In addition, because Mr MF’s prescription had been for single-dose bottles a separate ‘measuring jug’ had not been prescribed by the doctor.


“Mr MF’s prescribed dose of Methadone was 54ml daily. As such, when Mr MF was given the 100ml, 156ml and 500ml methadone bottles on the 15th April 2020, he was not given anything to accurately measure his daily dose from them.


“It is therefore probable, that due to a lack of a measuring jug, Mr MF guessed his first dose from the larger methadone bottles with tragic consequences.


“Had Mr MF been given daily dose bottles of methadone as prescribed, or a measuring jug and instructions on how to use it had been provided, on a balance of probability basis his death would not have occurred.”


You can read the full prevention of future deaths report here.


In a separate article lawyer, Andrea James made comment on this case. You can read here article here.


This circular is being shared under the Open Government Copyright licence.




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PIP editor

A pharmacist led training provider.

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