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.

 

 

Coroner highlights inability to access GP records

 

On 15th April 2020, Alison Mutch OBE, Senior Coroner for Greater Manchester South, opened an inquest into the death of Amy Hogan who died at Tameside General Hospital, on 21st January 2020, aged 23 years.

 

The inquest concluded that Miss Hogan died as a consequence of complications of deep vein thrombosis. Whilst this was acknowledged to be considered a natural cause of death, it is likely her death was contributed to by a recognised complication of the oral contraceptive pill.

 

The coroner highlighted multiple issues with accessing information about this patient on a number of occasions. Initially, there was a problem transferring the patient notes to her GP practice. On a second occasion when she was feeling unwell the out of hours doctor could also not access her notes.

 

From around September 2019, Miss Hogan began to report sporadic and non-specific symptoms of feeling unwell. Having initially attended the Pennine Medical Centre in Mossley as a visiting patient, Miss Hogan registered with that practice. Miss Hogan received treatment from doctors at the practice for depression and anxiety and continued to be prescribed the oral contraceptive pill following a risk assessment by the practice pharmacist.

 

On 20th January 2020, Miss Hogan attended the out of hours doctor at Oldham Primary Care hub, reporting a 3-day history of feeling lightheaded, weak and drained. Whilst Miss Hogan had told others she had experienced breathlessness and leg pain.

 

This information was not conveyed to the out of hours doctor. Whilst Miss Hogan disclosed to the doctor details of the anti-depressant medication she had been prescribed, he was not informed she was taking the oral contraceptive pill.

 

The following day, Miss Hogan became acutely unwell and collapsed at her home. She was taken to hospital by ambulance where she sadly died.

 

Commenting on the circumstances of Miss Hogan’s death the coroner for Manchester South Christopher Morris commented:

 

“The inquest heard evidence from Miss Hogan’s regular GP that, despite being requested, the General Practice records from her previous practice never arrived. It is a matter of concern that delayed, incomplete or non-existent transfer of patient data from one practice to another on moving places an unfair burden on patients to accurately recall and relay their own medical histories.

 

“It is a matter of particular concern that such issues create particular problems for vulnerable patients, who simply may not be in a position to do so.

 

“Notwithstanding numerous previous initiatives as to information-sharing and digitisation of patient data, it is a matter of concern that the out of hours GP reviewing Miss Hogan had no electronic access to her regular GP records. Access to such records would have revealed, amongst other things, Miss Hogan was prescribed the oral contraceptive pill, which is likely to have led the doctor to ask additional questions about her symptoms.

 

“Again, it is a matter of particular concern that an inability to access regular GP records in the out of hours setting raises additional risks for vulnerable patients.”

 

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