Source · Prevention of Future Deaths
Steven Fone
Ref: 2017-0101
Date: 27 Mar 2017
Coroner: Christopher Murray
Area: Manchester (South)
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryThe coroner noted a pharmacy allowed customers to interchangeably collect each other's prescriptions without documented consent, raising concerns this practice could facilitate abuse, stock-piling, and increased risk of harm.
Date
27 Mar 2017
56-day deadline
11 Jul 2017 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 2
Coroner's concerns
The coroner noted a pharmacy allowed customers to interchangeably collect each other's prescriptions without documented consent, raising concerns this practice could facilitate abuse, stock-piling, and increased risk of harm.
View full coroner's concerns
In the circumstances it is my statutory duty to report (o you. _ During the course of evidence at the Inquest was informed that Adams Pharmacy permitted three separate customers in receipt of prescriptions to interchangeably collect each other's prescriptions_ No documentation was before the court to confirm whether consent had been given by any customer: would like to know whether this practice is approved of by the relevant regulator of pharmacies. It seems to me this practice could be open t0 abuse and facilitate stock-piling leading to an increased risk of harm or death to those prescribed medicines which have the propensity to be fatal if taken outside the recommended guidance_
Report sections
Investigation and inquest
On 4"h November 2016 commenced an investigation into the death of Steven Thomas Fone. The investigation concluded on the 23" March 201 and the conclusion was one of misadventure. The medical cause of death was 1a) Combined toxic effects of tramadol, cocaine, amitriptyline, methadone, pregabalin and heroin:
Circumstances of the death
Steven Fone died on 31st October 2016 at Ashton under Lyne following the consumption of a fatal cocktail of tramadol, cocaine, amitriptyline; methadone, pregabalin and heroin:
Action should be taken
In my opinion action should be taken t0 prevent future deaths and believe you have the power to take such action.
Similar PFD reports
Report details
- Reference
- 2017-0101
- Date of report
- 27 March 2017
- Coroner
- Christopher Murray
- Coroner area
- Manchester (South)
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 11 Jul 2017 (estimated from the Judiciary.uk publication date).
Sent to
- Adams Pharmacy
- the relevant regulator of pharmacies