A GP surgery in Milton Keynes has implemented two new policies on prescribing following the death of a patient with a “documented history of prescription medication misuse and overdose”.
According to a prevention of future deaths report published on September 16, Alison Thomas was a patient at the Grove Surgery in Milton Keynes when she died in 2025, aged 58.
Coroner Sean Cummings noted that Thomas “had taken a large amount of different prescribed and over-the-counter medication” before her death, but said he was “unable to reach a conclusion of suicide” due to insufficient evidence.
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The report stated that Thomas had an “extensive mental health history”, chronic obstructive pulmonary disease and had been “deliberately restricted” to weekly prescriptions of codeine due to a “known risk of abuse and self-harm”.
At the time of her death, Thomas was found to be in possession of large amounts of gabapentin, oxycodone and Oramorph, as well as a month’s supply of codeine, which had been prescribed by her GP after Thomas said she would be travelling to France for a month-long holiday.
The report also said that Thomas had acquired diphenhydramine, a sedating antihystamine available over the counter at pharmacies.
Coroner’s concerns
Cummings highlighted at the time of Thomas’ death, the Grove Surgery’s medicines management policy contained no provision for the safe “prescribing, review, monitoring or quantity-control of long-term combined benzodiazepine, opioid or gabapentinoid medication”.
He noted that these types of drugs are subject to “extensive national guidance”, including multiple NICE guidelines due to their association with dependence and withdrawal symptoms, addiction and the risk of fatal respiratory depression.
The coroner also raised concerns about Thomas’ ability to obtain a month’s supply of codeine from her GP despite being placed on a restricted once-a-week prescription, and based on the “unverified assertion” that she was going on a month-long holiday.
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Cummings said that at the time of Thomas’s death, the practice “had no policy governing how requests for larger-than-usual quantities of medication for travel purposes, from patients known to misuse prescription medicines, were to be identified, assessed or authorised”.
“The deceased was known to the practice to misuse prescription medication and to have taken overdoses in the past,” he added.
The coroner expressed concern about Thomas’s ability to obtain opioids, gabapentin, high-dose temazepam and a benzodiazepine “in circumstances where she also had chronic obstructive pulmonary disease, an extensive mental-health history and a documented history of prescription-medication misuse and overdose”.
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He noted that the Grove Surgery had “no mechanism” in place to identify and prevent “the concurrent supply of multiple such medicines to a patient presenting this risk profile”, and described the policy in place at the time of Thomas’ death as “inadequate and 10 years old”.
And he said there is “a risk that future deaths could occur if patients with this combination of medication and risk factors are not systematically identified and reviewed”.
The Grove Surgery’s response
The Grove Surgery responded to the coroner’s report on September 2, stating that a “comprehensive medicines management and safe prescribing policy” had been implemented since Thomas’ death and made “accessible” to all staff on August 19.
It said the new policy, developed in line with multiple national guidelines and regulations, states that when prescribing “high-risk medication such as benzodiazepine, gabapentin or pregabalin, the prescriber should assess risks”.
Prescribers should also consider several factors, including the expected benefit to the patient, any history of substance misuse and potential risks of dependency and withdrawal symptoms, it added.
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According to the surgery, the new policy “specifically addresses the combined prescribing of opioid, benzodiazepine and gabapentinoid medication”, with patients taking these medications now subject to a review “prior to any new prescription being issued” and regular reviews scheduled for patients on taking the drugs “long-term”.
In addition to the policy, “audits will be conducted annually, led by the Practice Prescribing Lead and supported by the practice pharmacist”, alongside quarterly meetings to “discuss controlled drugs” from October.
“Enhanced scrutiny”
The surgery said it had also introduced a policy on “requests for medication to cover travel and periods abroad”.
It told the coroner the new guidelines ensure the “enhanced scrutiny” of high-risk medication requests and specify that “travel alone is not a sufficient reason” to alter prescription restrictions.
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The policy also states that where a patient is on a weekly prescribing regime, the clinician “should undertake a risk assessment, consider verification of the reason for a higher quantity and document their rationale and what safeguards have been put in place”, the surgery said.
The Grove Surgery added that it had taken the concerns raised by the coroner “extremely seriously” and that it is “committed to learning from this inquest to improve the care of patients at the practice and to mitigate any risk of future deaths”.
