Source · Prevention of Future Deaths

Marcus Hamilton

Ref: 2018-0005 Date: 5 Jan 2018 Coroner: Andrew Bridgman Area: Manchester (South) Responses identified: 0 / 1 View PDF

The mental health service's rigid 28-day prescription policy for maintenance medication left a patient vulnerable during extended travel, providing unreliable advice about obtaining drugs illicitly abroad.

Date 5 Jan 2018
56-day deadline 2 May 2018 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths

Coroner's concerns

AI summary
The mental health service's rigid 28-day prescription policy for maintenance medication left a patient vulnerable during extended travel, providing unreliable advice about obtaining drugs illicitly abroad.
View full coroner's concerns
For a number of years MDH was on a maintenance programme with MXL, which he received on a 28 days prescription: In December 2015 MDH informed GMMH that he was (aking a long trip of 51 days, to Goa, India_ MDH was advised that he could only have a 28 prescription of MXL to take with him: He was only given a 28 prescription along with the necessary documentation for travelling with the drug: In discussion with the witness from GMMH (MDH's Recovery Worker) regarding the fact that MDH would clearly run out of his prescription maintenance MXL part way through his holiday the answer received was that there were drugs _in India and MDH would be 27lh the day day able to obtain some more MXL The witness accepted that it could not be certain that MDH (or any other service user) would be able to obtain their maintenance drug (MXL or other) and that such MXL that MDH managed to get hold of would probably have been from the illicit market: The same applying to any other service user for whatever maintenance drug: Whilst / accept that what was said does not likely represent GMMH policy what the witness was telling me was, in fact; the reality of the situation created by GMMHs policylprotocol.

Report sections

Investigation and inquest
On 12th July 2017 commenced an investigation into the death of one Marcus Dale Hamilton ("MDH"): The investigation concluded on the October 2017 . The medical cause of death was; 1a) Drug toxicity and the conclusion was; Drug related
Circumstances of the death
MDH was a long-term service user of the Trafford Drug Treatment Services over 20 years. MDH's death was caused by combined respiratory depressive effects of a number of drugs taken in slight excess and at such levels that none of them alone would have given rise to a fatality There was no evidence of deliberate intent.
Action should be taken
In my opinion there should be a review of GMMH's policy that currently appears to fail to accommodate the needs of service users leaving the UK for longer periods than the protocol provides for their prescription of maintenance mediation.

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Report details

Reference
2018-0005
Date of report
5 January 2018
Coroner
Andrew Bridgman
Coroner area
Manchester (South)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 May 2018 (estimated).

Sent to

Greater Manchester Mental Health NHS Foundation Trust

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