Warning to GP surgery over more deaths as woman prescribed excess medication

A coroner has warned that more people could die after a pensioner was given excess medication despite knowledge that she could be addicted to the pills.

The investigation into Margaret Feeney's death in April concluded on Monday, November 11, after Coroner Nieto found that the 78-year-old died due to taking excess prescribed medication she had become dependent on and addicted to.

The inquest found that she had access to excess medication because of medical prescribing decisions and arrangements leading up to a bank holiday period. Detailing the circumstances surrounding her death, Mr Nieto told how Ms Feeney was found dead at her home on April 1, 2024, by her friend and cleaner.

A post-mortem examination with toxicology identified the cause of her death as the combined toxic effects of prescribed medication, which she had taken in excess. She was also identified to have pneumonia, which contributed to her death, and a high total morphine level suggested the potential additional taking of a morphine-based substance.

Mr Nieto told how Ms Feeney had a long history of being prescribed benzodiazepines and codeine, the latter medication for pain for diagnosed conditions. Ms Feeney had become dependent on those medications and was recognised to overuse them and, as a consequence, she was given seven-day prescriptions.

On March 26, less than a week prior to her death, Ms Feeney's friend was concerned that Margaret was confused, and the friend and Margaret attended a GP appointment that afternoon. The GP wanted to reduce her diazepam and issued a prescription for a lower dose in a daily dose blister pack.

The codeine prescription was not altered and the new diazepam prescription was with Margaret on March 27. This was the week prior to the Easter holiday period - with a bank holiday on each side of the weekend.

Margaret had received her usual Monday prescription (25 March) including diazepam and codeine. With the new diazepam prescription received on March 27, Ms Feeney had an excess of five days of that drug. Because of the pending bank holiday, she received an early prescription of codeine on March 28, which meant she had four days excess codeine.

Mr Nieto remarked: "Clearly, given her recognised dependence and overuse, there was a real and foreseeable risk that Margaret would take excess diazepam and codeine that was available to her between March 27 and her death. In addition to the toxicological evidence, when she was found deceased, there were empty or near-empty blister packs from the excess medication prescribed to her.

"On the evidence, there is no reason to consider that Margaret had deliberately taken the excess medication to cause her own death." Detailing his concerns, Mr Nieto added: "In my opinion, there is a risk that future deaths could occur unless action is taken.

"I am concerned that measures are not in place at Macklin Street Surgery and Daynight Pharmacy to prevent prescription of excess medication to patients recognised to be at risk of overdose, either intentional or unintentional, who are ordinarily issued shorter period repeat prescriptions to reduce those risks. This situation arises when early prescriptions are issued due to statutory holiday periods when most pharmacies are likely to be closed.

"I have been informed that measures have been introduced to prevent excess prescribing by taking account of single-day bank holidays, but there are no measures relating to longer bank holiday periods (e.g. Easter). With electronic patient records and data systems, it seems a reasonable presumption that suitable solutions can be identified.

In my opinion, action should be taken to prevent future deaths, and I believe you (Macklin Street Surgery and Daynight Pharmacy) have the power to take such action." The surgery and pharmacy are under a duty to respond to the report by January 20, 2025, and the response must contain details of action taken or proposed to be taken.

If the response does not include these details, an explanation as to why must be provided. Derbyshire Live contacted Daynight pharmacy for a comment but had no reply, whereas Macklin Street Surgery refused to comment on the report.