Lack of national pharmacy alert system criticised in tragic opiate case


A coroner has highlighted multiple system failures, including the lack of a national pharmacy alert system, in an incident that ultimately led to the tragic death of a nurse. The nurse, who we will refer to as ‘Ms H’ from here on, improperly obtained sufficient quantities of opiate medication to result in her death.


Ms H, who had a long history of chronic pain from a neck complaint together with anxiety and depression developed an addiction to pain-relieving medication, notably Zapain.


At the inquest, it was accepted in evidence by her GP that there had been occasions when Ms H had been prescribed too much medication and also periods when she had requested repeat prescriptions prematurely.


When the weaknesses in the GP prescribing system were identified, the GP refused to prescribe further Zapain without a discussion with the patient. She refused to engage with the GP and no further prescriptions were issued by the practice for codeine or other opiates.


It was also heard in evidence that Ms H had been found to have forged prescriptions during her employment as a practice nurse in order to obtain further prescription medication illicitly.


This led the NMC to strike her off the nursing register.


It became clear during the inquest that Ms H had continued to source codeine and (it is believed) amitriptyline (as well as other prescriptions, eg, propranolol and modafinil) after April 2018. From packaging recovered by her GP after admission to the hospital in 2019, it is believed Ms H obtained this from a number of on-line pharmacies.


The coroner’s report has highlighted that it is highly likely that other on-line pharmacies may have been approached.


The identity of the doctor(s) who gave Ms H a script for the medication, (notably codeine or other opiates) has not been established but it was heard in evidence that her registered GP had not been contacted by any other doctors who are likely to have been approached privately by the nurse.


Commenting on the case and in doing so highlighting the matters of concern the coroner said:


“During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken.


“The GP who gave evidence at the inquest stated that she had never been contacted by another doctor considering the prescription of opiate or other medication to Ms H. She was able to procure the medication in sufficient quantities first to require emergency admission to the hospital and latterly to result in her death.


“Similarly, the registered GP was not contacted by any dispensing pharmacist checking whether the prescription was appropriate.


“After the GP became aware of the two on-line pharmacies who had dispensed the medication to Ms H that led to her admission into hospital, she attempted to raise an alert through NHS England, in order that the undesirability of prescribing opiate medication to Ms H could be raised with clinicians. This was sent out regionally but the GP has since been advised there is no formal procedure for circulating patient alerts to pharmacies on a national level.


“I am further given to understand that non-NHS contacts would only receive a redacted version of the alert in any event.


“What seems clear is that the alert proved ineffective in preventing Ms H from improperly obtaining sufficient quantities of opiate medication to result in her death.”


You can view the complete coroner report here. 


Elements of this article are being shared under the Open Government Copyright licence.




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PIP editor

A pharmacist led training provider.

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