Source · Prevention of Future Deaths

Deanne Smith

Ref: 2014-0141 Date: 31 Mar 2014 Coroner: Dr R N Palmer Area: London (South) Responses identified: 1 / 2 View PDF

The practice of dispensing large quantities of methadone to drug-dependent individuals over public holidays increases the risk of future deaths and needs policy review.

Date 31 Mar 2014

56-day deadline 26 May 2014 est.

Responses identified 1 of 2

Alcohol, drug and medication related deaths

Coroner's concerns

AI summary

The practice of dispensing large quantities of methadone to drug-dependent individuals over public holidays increases the risk of future deaths and needs policy review.

View full coroner's concerns

The evidence heard at the inquest concerns me in that at times of public holidays; such as Christmas and New Year; when the usual pharmacy is closed for some ofthe days, an appreciable quantity of methadone is dispensed and provided for the individual to use on days over the holiday period. When the individual is dependent on opiates and is known to acquire opiates both legally and illegally; it seems appropriate to question to wisdom of providing several days' supply at one time I invite the and Alcohol Service and the Pharmacy to reconsider their policies and procedures for the provision of methadone to drug-dependent individuals at times of public holiday when the usual methods of provision are suspended. If drug-dependent individuals are permitted to take away several days' supply in one visit; there must remain a risk of future deaths; Part of a coroner at an inquest is to make a report such as this, intended to assist in the prevention of future deaths

Responses

1 respondent

United Pharmacy

PDF

Action Taken

United Pharmacy pharmacists are working closely with patients' special workers, having regular meetings with Bromley Drugs and Alcohol services, and will encourage services to use pharmacies open at weekends for medication pick-ups. (AI summary)

View full response

27 MAY Z2016 United Pharmacy 5 The Parade, Croydon RD Anerley. London: SEZO 7AA Tel/Fax: 020 87788285 7715hy Coroner's Office St Blalse Building Bromley. BR1 3UH Dean Thank you for sending me the Prevention of Future Deaths Report: In response please find the following actions taken;
1. United Pharmacy' $ phamacists are already working dosely wlth patient' $ special workers In order to exchange informatlon on clients using the Bromley Drugs and Alcohol services in order to make sure patient' $ are their medication on time:
2. We have regular meetings (at least twlce vearly) with Bromley Drugs and Alcohol services where we can openly discuss our concerns about the service wlth the prescribers:
3. For patients who have relapsed or not taking thelr medlcatlon on regular basis, we will encourage the services to use pharmacies that are open at weekends and bank Holidays as a base for picking up their medication on those spectfic days to reduce the amount of medication taken home: If you need any further Information please contact me at the above address:

Report sections

Investigation and inquest

On 8th January 2013 commenced an investigation into the death of Deanne Naomi Smith, born on 29 May 1978 and who died on 8 January 2013. The investigation concluded at the end of the inquest on 28 March 2014.

Circumstances of the death

Deanne Smith was dependent on Because of concern about the high dosage of medication she requested from her general practitioner; the GP referred her to the local and Alcohol Dependency Unit: Deanne was assessed by Bromley and Alcohol Service, first on 23 February 2012 and again on ] 8 December 2012 Her treatment plan included supervised consumption of 7Omg of methadone daily which was to be changed to daily unsupervised consumption after three consecutive free urine samples. On 18 December 2012 Deanne reported that she had relapsed and had been using €40-E60 heroin a day: The treatment plan following this appointment was to commence on 3mls_ methadone which was to be increased gradually to SOmls in line with titration guidelinesDeanne was to be reviewed in 3 months time but died on 8 January_

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you or your organisation the power to take such action.

Copies sent to

DR R N PALMER, H,M: COAONER SOutHeaN JurisdicTION OF GREATER LONDON

Similar PFD reports

Shared signals

Report details

Reference: 2014-0141
Date of report: 31 March 2014
Coroner: Dr R N Palmer
Coroner area: London (South)

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 26 May 2014 (estimated).

Sent to

Bromley Drug and Alcohol Service

United Pharmacy

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.