Coroner Alison Mutch has raised concerns about a GP practice’s lack of “detailed planning or oversight” over patients’ who are prescribed opioids long-term following the accidental overdose of a patient.
In a prevention of future death report published this week (May 19), the senior coroner for Manchester South said that “Louise Danielle Rosendale was prescribed long term opiates for pain following previous surgery”.
Read more: RPS issues polypharmacy warning as SMRs ‘missed or de-prioritised’
Rosendale was prescribed the drugs “for many years despite the risks associated with long-term opiate prescribing”, the report added.
Despite this, the inquest found that “there had been very limited attempts to review” her prescription.
“No planning”
The report said that while Rosendale was “identified as a patient on a long-term opiate prescription in 2022”, “the next action had been a pharmacy review in July 2024” – some two years later.
It remains unclear whether this review took place.
Read more: Why I’ll miss primary care pharmacy’s focus on structured medication reviews
“There was no evidence of long-term detailed planning or oversight of…patients [on long-term opioid prescriptions] within the practice,” the reported added.
Rosendale was found “unresponsive” in September 2024 – “she had died from a combination of multiple drug toxicity and pneumonia”, it said.
“The conclusion of the inquest was accidental death,” it added.
“Action should be taken”
Mutch sent her report to Rosendale’s GP practice and to Greater Manchester Integrated Care Board (ICB).
“In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action,” she wrote to them.
Read more: ‘Excessive’ GP pharmacist workload leaving safety ‘gaps’, warns CQC
Greater Manchester ICB yesterday (May 20) told C+D that it is preparing its formal response to the coroner.
Its thoughts remain with Rosendale’s family and all who loved her, it added.
C+D approached her GP practice for comment.
SMRs ‘missed or de-prioritised’
The report comes after the Royal Pharmaceutical Society (RPS) last year warned that pharmacists working in primary care networks (PCNs) were “moving away from” structured medication review (SMR) delivery.
At the time it highlighted that the requirement for PCNs to detail measures taken to “improve medicines optimisation including SMRs” under their 2024/25 contract is “non-contractual”.
Read more: Structured medication reviews mark a huge success for PCN pharmacy
It raised concerns that the new contract could SRs “missed or de-prioritised by hard-working practices”.
“With continued pressures across the health service, our members have warned that pharmacists are being re-directed from delivering structured medication reviews and tasked with other activities,” RPS England vice-chair Brendon Jiang said at the time.
