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.




Andrea James comments on methadone toxicity case


A prevention of future deaths report published this week stated the following:


“Had Matthew 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.”


It is not very common for Coronial Prevention of Future Deaths Reports (PFD), to specifically relate to actions in community pharmacy. However, one published this week does precisely that. The case arises from the death of a young man, Mr MF, following a methadone overdose in April 2020.


At the start of the Covid-19 pandemic in 2020, Public Health England advised that individuals on opiate replacement treatment including methadone should be moved from short term (daily or tri-weekly) prescription collections to longer intervals.


In the case of Mr MF, his methadone collection was changed from three times per week to fortnightly.


His prescribing doctor stipulated that Mr MF’s dose was to be provided to him in single, daily dosage bottles each containing 54ml of methadone.


Unfortunately, Mr MF’s community pharmacy dispensed his methadone in three large bottles, each containing as much as 500ml of methadone, and did not provide a measuring jug. Mr MF was found dead shortly after collecting his prescription and his cause of death was recorded as methadone toxicity.


As Mr MF had been doing well in his recovery and there was no indication of any intention to die by suicide, the Coroner concluded that, due to the lack of a measuring jug, Mr MF guessed his first dose from the large methadone bottles provided to him and accidentally overdosed.


The Coroner found that had Mr MF been given daily dose bottles of methadone as prescribed, or a measuring jug and instructions on how to use it, on the balance of probability his death would not have occurred.


Under the Coroners and Justice Act 2009, coroners are obliged to report about deaths with a view to preventing future deaths.  These reports are known as Prevention of Future Deaths Reports, or PFDs.  As a result of Mr MF’s death, the Coroner has issued a PFD to Public Health England, the General Pharmaceutical Council and the individual community pharmacy which dispensed Mr MF’s methadone.


As the Chief Coroner’s guidance makes clear, PFDs are “not intended as a punishment; they are made for the benefit of the public” and are “intended to improve public health, welfare and safety”. However, being the recipient of a PFD is a serious matter. Almost all PFDs are published by the Chief Coroner and become a matter of public record.


Further, the recipient of a PFD has a legal obligation to respond to the Corner within 56 days providing either (a) details of all action taken, or proposed to be taken, and a timetable for action, or (b) a cogent explanation as to why no action is proposed.


We will update this blog with the responses provided by the General Pharmaceutical Council and other PFD recipients once they are available. The full published PFD appears linked below.


Andrea James is a partner at Brabners LLP. You read about her role by clicking here. She invites readers not to hesitate to her or another member of Brabners’ Healthcare Regulatory Team should you need assistance in relation to any Inquest or PFD matter. You can reach by email by clicking here.



£1.9 million to move Scottish prisoners from methadone to buvidal


Prisoners in Scotland will be moved from methadone to buvidal, £150,000 will be invested to support residential rehabilitation for people leaving prison and the supply of naloxone is to be expanded.


These new measures have been designed to assist those affected by drug use during the COVID-19 pandemic have been announced by the Scottish Government.


The measures specifically include the following:


  • £1.9 million to support people in prison on prescribed Opiate Substitution Treatment (OST) to switch to a new longer-acting form called buvidal.
  • £150,000 for an enhanced offer of residential rehab to people leaving prison during the pandemic to support their recovery and to reduce the pressure on local services.
  • widening the availability of overdose reversal drug Naloxone while measures to tackle coronavirus remain in place.


Public Health Minister Joe FitzPatrick said:


“While this public health crisis is ongoing, we must not lose sight of the fact there continues to be a significant number of highly vulnerable individuals who are at great risk of harm as a result of alcohol and drug use, who continue to need a wide range of help and support.


“Buvidal is an alternative to methadone or buprenorphine tablets which is administered by a seven or 28 day injectable dose, rather than daily administration. By making this available to people in prisons, we will support continuity of care, while reducing the need for daily contact and reducing pressure on our front line prison officers and NHS staff.


“Furthermore, a high proportion of those leaving or about to leave prison will require support for their recovery from problem alcohol or drug. Funding to pay for additional residential rehabilitation places will support their recovery and to reduce the pressure on local services.


“I welcome the Lord Advocate’s statement of prosecution policy in respect of the distribution of naloxone during the period of disruption caused by COVID-19. This will help to ensure that we can continue to support those affected by drug use and keep them safe.”


Cabinet Secretary for Health and Sport Jeane Freeman commented:


“We’ve already announced a number of measures to ensure that treatment and support services are not disrupted, during this crisis.  As part of that, we have increased the availability of naloxone – a medication which reverses opiate overdose.


“Under existing UK legislation, supplies of naloxone can be held by non-drug treatment services for use in an emergency, but not for onward distribution.  In the current crisis that could present an obstacle to people receiving the treatment that they need.


“So that’s why the Lord Advocate has confirmed that for the duration of this crisis it would not be in the public interest to prosecute any individual working for a service registered with the Scottish Government who supplies naloxone in an emergency, to save a life.


“I hope that statement provides confidence and certainty to relevant professionals, as they carry out their important work.  And I hope it will further ensure that people can get the treatment they need when they need it.


“I am also announcing today new support for people who are in prison or about to leave prison.


“We are providing £150,000 to enhance residential rehabilitation services.   It will increase the number of residential places available, for people leaving prison.


“And we are making up to £1.9 million available to support people in prison, who need opiate substitution therapy – or OST as it is known.  That is currently around a quarter of Scotland’s prison population.


“The funding will make a new treatment – called buvidal – available to people in prison. Unlike other substitutes, buvidal is administered as a 7 or 28 day injectable dose, rather than daily.


“This change will help to relieve pressure on our prison service.  It will ensure continuity of treatment, for people in prison.  And it is a further way in which we are trying to provide the right support during this pandemic, to those who need it.



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


Innovative pharmacy technician tackles opioid crisis

Alyssa Stanlake


Alyssa Stanlake is a Canadian pharmacy technician who works as an operations manager in a community pharmacy in Whistler. Alyssa works for Pier Health, a community pharmacy which specialises in supporting people who have an addiction and mental health problems.


She was awarded the honour of Canadian Pharmacy Technician of the Year 2018 after being nominated by her employer.


In the relatively short time that Alyssa has worked for them as operations manager, she has introduced a scheme whereby patients and residents can access naloxone kits free of charge. She has also instigated training so that everyone who has a kit knows how to use it.


Alyssa explained to me how she has saved many lives and educated a community as a consequence of this project.


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