Inquest criticism over toxicity death

Deaths from toxicity of prescribed medication – typically opiates and pregabalin – is a common theme in inquest cases handled by Medical Protection and is a ‘hot topic’ for coroners. This case demonstrates how Medical Protection can prepare members for inquests and reduce the risk to their professional welfare.

The case

Mr A was a man in his mid-40s, registered at the practice where Dr E was one of five partners. Mr A had a history of chronic pain from pancreatitis and a subsequent pancreatectomy. He had been on fentanyl patches, oxycodone and gabapentin for approximately ten years. It was recently known that Mr A abused alcohol and heroin and he had spent some time in prison. The practice had managed to reduce the dose of fentanyl and his prescription requests were monitored to ensure he was not over-ordering. The practice reviewed Mr A’s medications every 6-12 months.

In March 2019, soon after a medication review, Mr A was remanded in custody. During his time in prison, the prison healthcare team had reduced his opiate use and, on release, he was no longer on gabapentin or fentanyl patches. The prison healthcare team had given Mr A a discharge summary for him to pass on to his GP, but he did not relay this to the practice. Within days of leaving prison, he was admitted to ITU following a heroin overdose. The discharge summary to the practice from the hospital did not include gabapentin or fentanyl.

The practice had not been aware of the changes to Mr A’s usual medication and therefore continued to provide him with his prior dose of gabapentin and fentanyl when he requested it. About six weeks post release from prison Mr A was found dead; he had self-administered two fentanyl patches. The postmortem/toxicology report cited the cause of death as: 1a fentanyl toxicity and 2. cocaine use.

Dr E contacted Medical Protection for assistance in providing the initial report for the coroner. It was identified that the practice would likely be called to give evidence as an Interested Party and a solicitor was instructed early on in the case. The medicolegal consultant and solicitor met with Dr E to explain the inquest process, what to expect and the possibility of being called to give evidence, and explained that legal representation would be provided. The medicolegal consultant was able to work with Dr E to identify areas where the practice would be at risk of criticism and explained the repercussions of being criticised at an inquest. The practice was very proactive: they held an SEA and instituted an action plan to reduce the likelihood of future occurrences. The practice took the following actions:

• All discharge summaries following significant admissions to be work-flowed to a clinician so that discharge medications can be cross-referenced with the repeat prescription list on record.
• For all patients on opioids to have the number of items issued set at a minimum number of days to reduce the risk of over-ordering.
• Any anomalies in requests for repeat prescriptions (such as long gaps between ordering) to be flagged to the clinicians.
• Regular reviews of all patients on opioid medication, with a view to reducing the dosages wherever possible. All patients on opiates to be informed of these regular reviews by letter.

Despite the good work undertaken by the practice, the coroner was critical of both the prison medical service and the practice. The criticism of the practice was: “Mr A had incorrectly remained on the repeat prescription list. They [the practice] should have removed Mr A as he had not been able to collect a prescription since February 2019.

“No-one who had involvement with these prescriptions noted that Mr A had not received prescriptions for 12 months, that he had recently been an inpatient for three weeks following an overdose or that his annual medication review had not been done. Mr A should have had an appointment to discuss his medications. His GPs should have ascertained that he had been prescribed morphine sulphate and that his fentanyl had been stopped.

“If Mr A had been spoken to, on the balance of probabilities it is more likely than not he would not have been prescribed fentanyl; at the very least he would have been started on a much lower dose, such as 25 mg/l as opposed to the 100mg/l he received.”

The coroner concluded the verdict as: “Misadventure contributed to by neglect.”

The practice response

Given the criticism of the practice Dr E was counselled regarding self-referral to the Medical Council. Dr E self-referred and was thanked by the Medical Council, who were satisfied with the work undertaken by the practice and closed the case with no action.

This was a very difficult time for Dr E. They had been called to represent the practice and although Dr E did have contact with Mr A and was involved in some of the repeat prescriptions being issued, they were not the only clinician involved and the issues around processes within the practice was the responsibility of all the partners. In this case the burden was shouldered by only one clinician. For this reason, when receiving requests for reports from the coroner the practice should consider who is best placed to provide reports and representation at inquests, and share the load wherever possible. If there are any concerns regarding potential criticism, we would advise our members to contact Medical Protection early on and certainly before providing any reports to the coroner.