Layer 1

Sector should reflect on methadone dispensing after overdose case

Suffolk's senior coroner, Nigel Parsley (Credit: Coroners' Society)
Suffolk's senior coroner, Nigel Parsley (Credit: Coroners' Society)

The “extremely sad case” of a patient’s methadone overdose provides pharmacy teams an “opportunity to reflect” on their substance misuse services, a patient safety lead has said.

Matthew Colin Fitten was found deceased at his home in Haverhill, Suffolk on April 17 last year by a relative.

According to a coroner's report, toxicology analysis identified a toxic quantity of methadone in Mr Fitten’s blood at the time of his death, which the coroner attributed to his prescription changing from being dispensed three times a week in daily dose bottles, to once a fortnight, due to COVID-19 restrictions that had recently come into effect.

The coroner’s report said that, at the outset of the COVID-19 pandemic, the charity Turning Point, which was supporting Mr Fitten with his "drug dependency issues", was given guidance by Public Health England (PHE) “that individuals on opiate replacement treatment (methadone) should be moved off short-term (daily or tri-weekly) prescription collections to longer-term ones”.

Despite the patient's doctor stipulating that the methedone prescription still be dispensed in daily doses, when Mr Fitten went to his pharmacy on April 15, 2020, the methadone he was given was not in daily doses, but rather in bottles of 100ml, 156ml and 500ml, the coroner claimed.

Haverhill Pharmacy was contacted for comment, but had not responded by the time this article was published.

Due to his prescription being for single dose bottles, Mr Fitten was not given a measuring jug by his doctor to accurately measure out the 54ml of methadone he was supposed to take daily, according to the coroner’s report.

“This meant Matthew had a much larger quantity of methadone than he would normally have,” Nigel Parsley, senior coroner for the Suffolk area wrote in his report.

Mr Parsley offered a “probable” explanation for Mr Fitten’s death: “Due to a lack of a measuring jug, Matthew guessed his first dose from the larger methadone bottles, with tragic consequences.”

Mr Fitten would not have died "on a balance of probability" if he had either been given the daily doses of his methadone or a measuring jug and instructions on how to use it, Mr Parsley wrote in his report.

Despite risk mitigations put in place by Turning Point, his “access to increased quantities of methadone directly contributed to his death”, Mr Parsley wrote.

Lessons to learn and share

A spokesperson for the General Pharmaceutical Council told C+D that it has “opened an investigation into the regulatory concerns arising from the incident covered” and this investigation is “ongoing”.

Meanwhile, Janice Perkins, chair of the Community Pharmacy Patient Safety Group (CPPSG), told C+D that this “extremely sad” case “highlights the risks that reduced frequency of collections can create and provides important learnings that need to be shared to prevent similar occurrences in the future”.

Ms Perkins explained that providing substance misuse services during the initial months of the COVID-19 pandemic had posed “a number of challenges for community pharmacy” and the CPPSG had “worked through” some cases.

In these scenarios, the CPPSG had tried to “ensure a balance between patient safety, colleague safety and compliance with lockdown rules and best practice”, Ms Perkins explained.

Read her advice for pharmacy teams providing substance misuse services below.

What can pharmacy teams learn from this case?

“When dispensing methadone, pharmacists must follow best practice and take a patient-centred approach, which considers the individual needs and circumstances of the patient.

“It is imperative that patients receive sufficient counselling to enable them to understand changes to their prescription. Regular contact should be maintained to ensure any issues can be identified early and raised with the prescriber.

“We recommend a maximum seven days’ supply is issued per collection. It’s important to assess the benefits and the risk of any changes to prescribing frequency. This should take into account the patient’s circumstances and particularly the storage arrangements at home and their family situation, especially if they have children.  

“To reduce the risk of error, in line with best practice medicine should always be supplied in single dosage bottles. If for any reason this is not possible then a suitable measure must be provided and the patient must be shown how to measure the correct volume.

“As lockdown restrictions ease, we also recommend the appropriateness of prescription changes are revisited and reviewed to further minimise risks and that the best treatment schedule is agreed between the patient, the prescriber and the pharmacy team. It’s important that changes are spread out across the week to help pharmacy teams manage their workload, order stock appropriately and maintain COVID-secure arrangements for all patients.”

Some positive takeaways 

“On a more positive note, for some patients, the changes to the frequency of methadone collections as a result of the pandemic has been beneficial, improving quality of life, reducing the need to visit the pharmacy helping them to better manage their lives.

“Anecdotally, it has also removed some of the stigma that patients felt about feeling they were being treated differently due to their health condition. This is an opportunity for community pharmacy teams to reflect on the approach taken to supporting these patients and fully meet their, sometimes complex, needs in an empathetic and inclusive way.”

Source: Janice Perkins, chair of the Community Pharmacy Patient Safety Group (CPPSG)

Does your pharmacy offer a supervised consumption service?

Interleukin -2, Community pharmacist

We can debate till we all blue in the face but one thing is for sure...some poor pharmacist will most likely have questions to answer and neither the prescriber nor the drug suport team will take any blame for this. The service is underfunded and the quality of prescribing due diligence and safeguards have dropped over the years..I even get scripts now withouta named prescriber just some squiggle with no annotations as to the qualifications or authority of the prescriber. Apparently a named prescriber I was once informed is not a legal requirement for SCH2 and 3 CDs..

Ben Merriman, Community pharmacist

The name on the prescriber on the Rx is used solely for statistical/pricing purposes as there's no legal requirement for it.  A non medical prescriber should have their qualifications on the Rx but don't think their name needs to be on the Rx.

Adam Hall, Community pharmacist

So, by following PHE advice, this pharmacy is being set up as the 'fall guy' at a time when EVERYONE (not just, but especially, pharmacy) was struggling with the demands of the first lockdown and, in the particular case of pharmacy, a huge jump in workload at a time when everyone else was closing their doors to patients.

N O, Pharmaceutical Adviser

Hopefully there is a learning for DoH as well. Which is, fund the service properly. Pay a dispensing fee for each instalment (daily) and bingo every pharmacy will sign up for this and give in an individual bottle with a measuring cup if required.

TC PA, Community pharmacist

If the script specified doses to be supplied in advance in individual bottles then you can claim PD fees for each bottle supplied e.g. for a 2 week script you could claim one CD fee plus 13 PD fees.

If the prescriber specified on the script that doses needed to be supplied in daily containers, I'm afraid the pharmacy is at fault. I'm not saying the pharmacy is completely to blame for this tragic incident, that is for the investigators to determine. I've had as many as 30 daily methadone/buprenorphine patients in the previous pharmacies I've worked in so I appreciate how time consuming the service is to provide. I don't miss it one bit.

Ashish Patel, Pharmacy owner/ Proprietor

surely the overiding factor here is that he was prescribed 2 weeks in one go and temptation was too much rather than indiv bottles

C A, Community pharmacist

"An additional “Packaged Dose” fee of 55p can be claimed per additional packaged dose supplied, where the individual doses have been packaged separately (by this, it is meant that each individual dose is packaged in a separate container). The number of additional packaged doses claimed must be clearly endorsed on the prescription as payment of this fee will be based on the endorsement given only.


Decisions related to frequency of collection continue to lie with the prescriber. However, contractors have the professional discretion to dispense individual doses in separate packages as appropriate."


PSNC cover installment dispensing and fees quite well, along with a bit of professional information.

N O, Pharmaceutical Adviser

All well said. But when it comes reimbursement, if the prescriber has not mentioned individual doses to be dispensed separately then you don't get paid for the extra bottles supplied, no matter what you endorse. It would be interesting to see what the prescriber mentioned in this case.

Ben Merriman, Community pharmacist

Contractors may still supply and will be paid for daily dose containers regardless of whether or not the prescriber has requested this:

If daily dose containers are requested but not supplied, this should be documented in the patient's records with justification.

Re: "measuring jugs", contractors are paid a container allowance for each item to provide a suitable measuring device (e.g. 5mL spoon, 1mL, 5mL or 10mL oral syringe).  No provision is made for supply of a measuring cup however. 

N O, Pharmaceutical Adviser

Have you ever checked your FP34C? The NHSBSA seems to ignore our endorsements and go by what is on the Rx I'm afraid.

C A, Community pharmacist

Aren't FP10MDAs sent in the Red section of the FP34c for hand processing?

Ben Merriman, Community pharmacist

That shouldn't be the case. FP10MDA Rx are processed by hand (and can't yet go EPS from memory) so endorsements should be taken into account

Job of the week

Pharmacist Manager
Midlands, Cheshire & Dorset
Salary dependent upon experience