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.




Multiple failures linked to tragic acute anaphylaxis death


Shanté Andreé Marie Turay-Thomas was allergic to nuts and on 18th September 2018, she told her mother that she had eaten hazelnuts. Shanté tragically died of acute anaphylaxis in September 2018 shortly after.


At the conclusion of the subsequent inquest, the coroner wrote to senior leaders and organisations to highlight these concerns. He outlined his concerns that future deaths may occur if actions were not taken to prevent.


The failings were far-reaching and involved multiple people and organisations involved in Shanté’s care. Her general practitioners, the NHS 111 call handling team, the company who manufactured the adrenaline pen and event the National Institute for Health & Care Excellence were criticised.


Of relevance to pharmacists and pharmacy teams were the references the coroner made to the switching of brands of adrenaline pens and also the dosing.


The GPs had not identified Shanté (who had a high BMI and was severely allergic) as being at particularly high risk from her allergies and asthma and had no awareness that they were the sole providers of Shanté’s allergy care.


Shanté’s GPs knew that she should carry two adrenaline auto-injector (AAI) pens at all times, and they may have mentioned this to her, but they failed to record this and they did not emphasise it to her.


They failed to emphasise to Shanté and her family that the reason for carrying two pens is primarily because in the event of severe acute anaphylaxis, the very strong likelihood is that both pens will need to be administered, one five minutes after the other, to keep the patient alive until the arrival of an emergency ambulance.


The GPs did not explore with Shanté the reason for her erratic requests for a pen. They did not explore with her where she kept her pens. They did not test her understanding of medical advice.


The Emerade AAI accompanying leaflet does include the advice that two pens should be carried at all times, but the advice is not re-iterated on the outside of the box.


The Emerade AAI is sold singly. It could be sold in boxes of two as the norm and only singly in the alternative.


When Shanté’s AAI was changed from an EpiPen to an Emerade, her GPs failed to reconsider the prescription and to increase her dose from 300mgs to 500mcgs.


Following the scriptswitch, the GPs failed to ask Shanté to come into the surgery for training in the use of the Emerade. The coroner highlighted that this would also have presented an ideal opportunity to explore Shanté’s understanding of the use of her pens and to ensure that she understood she needed to carry two at all times.


The GPs relied upon the advice given by Enfield Clinical Commissioning Group (CCG) that the scriptswitch was simply the replacement of one branded product with another branded product of the same drug/device. This gave false reassurance. The CCG joint formulary committee introduced a new drug for GPs but then gave the wrong advice to accompany this.


The CCG failed to draw prescribers’ attention to the need, following scriptswitch from EpiPen to Emerade, to reconsider the dose and to prescribe the higher dose of 500mcgs for patients at higher risk (which would have included Shanté).


The CCG failed to inform prescribers that the Emerade pen requires different training to the EpiPen because different AAIs do not operate in the same way. In fact, the CCG gave the opposite advice.


You can read the full coroner’s report below.


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You can read more about the anaphylaxis campaign here.


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



Emollient cream acts as an accelerant in fatal fire


A coroner in Stafford, England has raised concerns about the dangers of ‘petrol-based emollient cream’ and re-iterated the need to raise awareness of this potentially fatal issue amongst healthcare professionals.


The call comes after the death of Maureen Milton a 74-year-old lady. Ms Milton sadly died from burns after her clothing caught fire.


On 18th April 2019, fire crews were called to Ms Milton’s flat. The flat was smoke-filled when the fire crew arrived and unfortunately, Ms Milton was found in her lounge. She had passed away and was found to have died from her burns.


Toxicology reports confirmed that the cause of death was burning and not smoke inhalation. It emerged that she had been trying to light a cigarette with a match when her clothing caught fire.


The coroner’s report found that there was evidence of ‘petrol-based emollient cream’ which had likely soaked into her clothing. This flammable element was found to have acted as an accelerant for the fire.


Sadly in July 2019, Ms Milton refused to have a smoke alarm fitted to her personal alarm and carers also raised safeguarding concerns about the fact that she was a heavy smoker and may, therefore, be at risk.


Concerns raised


As part of the coroner’s report, a number of concerns were raised. Fire crews reported that they had been attending increased numbers of fires involving ‘mostly’ elderly people. These fires were often found to involve ‘petrol-based emollient cream’.


The report described the problem of these emollients, which are widely available over the counter. Over time the emollients soak into clothing and then present a fire hazard. In the event of any fire, the clothes will likely be engulfed in flames and the resultant death is likely to be due to burning rather than smoke inhalation.


The coroner made it clear that awareness of this serious issue amongst healthcare professionals needs to be better to prevent future recurrence.


Previous warnings


The incident in 2019 involving Mrs Milton comes after a number of Medicines and Healthcare products Regulatory Agency (MHRA) alerts and warnings. This issue was raised by the MHRA back in 2008.


In April 2016 the MHRA issued an alert highlighting the dangers of paraffin-based emollients. The alert advised that smoking or a naked flame could cause patients’ dressings or clothing to catch fire when being treated with a paraffin-based emollient that is in contact with the dressing or clothing.


Please find the most recent MHRA alert here. This latest alert was issued in December 2018.


As a result of these warnings, the following advice for healthcare professionals was issued.


  • Advise patients not to:
    • Smoke.
    • Use naked flames (or be near people who are smoking or using naked flames).
    • Go near anything that may cause a fire while emollients are in contact with their medical dressings or clothing.
  • Change patient clothing and bedding regularly—preferably daily—because emollients soak into the fabric and can become a fire hazard.
  • Incidents should be reported to NHS England’s Serious Incident Framework (includes Wales), or to the Health and Social Care Boards in Northern Ireland; for questions regarding alerts in Scotland, contact Healthcare Improvement Scotland.


You can read the full coroners report below and by clicking here. This information is subject to Crown Copyright and is being shared under the Open Government Licence. 


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