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Coroner: Give pharmacies ‘obligation’ to report failure to collect methadone

A coroner has raised concerns that pharmacies have “no apparent obligation” to report when a patient stops collecting methadone, after a man died when a pharmacy’s warnings were ignored.  

Earlier this month (February 8), coroner Robert Cohen found that 39-year-old Dayle Bates died of heroin, bromazolam, protonitazene, xylazine and alcohol intoxication just two weeks after he failed to pick up his methadone prescription from a pharmacy.

Assistant coroner for Cumbria Mr Cohen said that Mr Bates’ methadone prescription, under which “he was required to collect a dose each day from a named pharmacy”, had been issued by local addiction charity Recovery Steps.

“Shortly after” Mr Bates stopped collecting methadone on July 14 2023, the pharmacy “sought to inform Recovery Steps”, he added. 

But pharmacy workers “did not have any contact details other than a general number that [was] not always answered and a direct line for one key worker”, who they attempted to raise concerns with.

The message appeared “not to have been relayed” and the charity “did not become aware that Mr Bates was not collecting methadone until August 30”, the coroner added. 

The coroner’s report said that Mr Bates was found dead in his home the next day, on August 31.


“Risk of future death”


The coroner said that while the pharmacy had a practice of informing the addiction charity of any concerns, this was “a voluntary decision on their part”.

He added that there was “no direct means by which a pharmacy can report to Recovery Steps that a service user has stopped collecting methadone”.

“I am concerned that this situation gives rise to a risk of future death”, he said. 

He stressed that there was “also no apparent obligation on pharmacies to report wider concerns for service users’ welfare” to the charity, meaning it may be “unaware that vulnerable service users require additional support”.

Recovery Steps, which must respond to the report by April 5, told C+D this week (February 26) that it is “currently reviewing” the report and is “committed to making a full and timely response”.

Becky White, area manager for Recovery Steps Cumbria, said that the charity’s “main priority is always the safety and wellbeing of the people [it supports]”.

“We would like to acknowledge Dayle Bates’s tragic death and offer our condolences to his family and friends,” she added.


Pharmacies should “flag cases of over-prescribing”


Meanwhile, the Courts and Tribunals Judiciary last week (February 23) published a report sent to the General Pharmaceutical Council (GPhC) and Boots in 2018 that found that pharmacists should be a “failsafe device” in cases of potential overdoses.

The report looked at the death of Darren Carrington, who it said was issued “over twice the appropriate amount” of sleeping pill Zopiclone.

After conducting an investigation between April and June 2018, senior coroner for the City of Brighton and Hove Veronica Hamilton-Deeley found that Mr Carrington died from an “impulsive overdose whilst under the influence of alcohol”.

She raised concerns about “repeat prescriptions” for patients who are “very likely to be becoming dependent upon such medications or are misusing them”.

The coroner said she was “very worried” about GP receptionists and clinicians who can “override” the warnings in their surgery’s computer system. 

And she added that “the other ‘failsafe device’ is the dispensing pharmacist”.

“When repeats are requested online there is a designated pharmacy [and] they receive emailed scripts”, she said.

“Their own systems should flag up cases of over or too frequent prescribing as well as other matters”, she added. 


GPhC "considering learnings"


GPhC chief executive Duncan Rudkin told C+D yesterday (February 27) that the regulator was “very sorry to hear of the death of Darren Carrington”. 

“We reviewed the prevention of future deaths report in detail when we received it in 2018 and we continue to consider and reflect the learnings from this report and other similar reports in our work,” he said.

C+D also approached Boots for comment.

It comes after a coroner urged the medicines regulator and NHS England (NHSE) to "take action" in December following the death of a 35-year-old woman after taking the anti-nausea drug cyclizine, which she had purchased from a community pharmacy.

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