Welwyn man’s fatal overdose after stockpiling medication prompts coroner’s warning
PUBLISHED: 08:01 07 August 2020
A coroner has urged NHS England to take action to prevent future deaths after a man was able to stockpile repeat prescription medication and use it to take his own life.
An 84-year-old man, who had dementia, was found collapsed at home in Welwyn by a neighbour on September 19 last year. He died in hospital later that day, having overdosed on the strong painkiller Tramadol, for which he had a repeat prescription of 100 capsules per month for an extended period.
Tramadol is just one of several drugs he had on repeat prescription.
In fact he had amassed a large quantity of medication he was not taking.
During the inquest, Geoffrey Sullivan, senior coroner for Hertfordshire, heard evidence from a mental health nurse as a result of concerns over the extent of the drugs prescribed to him.
In a subsequent letter to Sir Simon Stevens, chief executive of NHS England, Mr Sullivan writes: “She outlined that [the man’s] case was far from unusual.
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“That she frequently visited patients who had amassed vast quantities of unused medication and medical supplies.
“Often these patients were older and with varying degrees of mental impairment.
These drugs were invariably on repeat prescription and the continued need for the drug and/or compliance with the prescribed regime was not adequately supervised. One patient had a ‘cupboard full’ of unused medication.”
He continues: “During the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that further deaths will occur unless action is taken.
“Repeat medication is not being adequately monitored, leading to many – often older and/or mentally infirm – patients building up dangerous quantities of prescribed medication.
“Also, the inadequate supervision of prescribed repeat medication is so widespread the consequent waste of resources has an adverse impact on the overall provision of healthcare.”
An NHS England spokesman said: “While serious patient safety incidents are thankfully rare, a medicines safety programme has already been established, meaning more than ever before is being done to ensure safe medicine use, and nearly £80 million has been invested in electronic prescription technology, and hundreds of NHS staff across the country are working with care homes to reduce over medication.”
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