Alison Thomas

(1) At the date of Alison Rose Thomas’ death, the practice operated a  Medicines Management Policy, but that policy contained no provision  addressing the safe prescribing, review, monitoring, or quantity-control of long-term combined benzodiazepine, opioid, or gabapentinoid medication. This is so despite these classes of medicine being the specific subject of extensive  national guidance, including NICE Guideline NG215 (Medicines associated  with dependence or withdrawal symptoms: safe prescribing and withdrawal  management for adults, April 2022), NICE Guideline NG193 (Chronic pain,  2021), and successive MHRA Drug Safety Updates addressing the risk of fatal  respiratory depression from opioids and gabapentinoids and their combination, and the dependence and addiction risks of opioids. I heard that a policy of this  nature is now being developed, but that the work remains at a very early stage  and that no such policy was in place atthe date of the inquest some seven  months after death. There is accordingly a continuing and unremedied risk that other patients receiving long-term opioid, gabapentinoid, or benzodiazepine  treatment are being prescribed for without the safeguards that national  guidance requires. 

(2) Alison Thomas’ codeine was deliberately restricted to weekly prescribing  because of a known risk of abuse and self-harm. Despite that restriction, she  was able to obtain approximately a month’s supply of codeine, together with  gabapentin, oxycodone and oral morphine (Oramorph), on the strength of an  unverified assertion that she was to travel to France for a month over the  holiday period. The evidence disclosed an inadequate system by which such a  request — for a quantity of medication markedly greater than usual, made by a patient who was subject to a deliberate dispensing restriction imposed for her  own safety — was risk-assessed or verified before the medication was  released. A safeguard that can be set aside for an unverified account of foreign travel, with no countervailing check, affords limited protection to a patient at  known risk. 

(3) At the time of Alison Thomas’ death the practice had no policy governing  how requests for larger-than-usual quantities of medication for travel purposes from patients known to misuse prescription medicines were to be identified,  assessed, or authorised. The deceased was known to the practice to misuse  prescription medication and to have taken overdoses in the past. I was told  that this deficiency has since been rectified. I have not, however, been  provided with the replacement policy or with evidence of its implementation,  and I am not yet in a position to be satisfied that the remedial measure is in  place and operating effectively. 

(4) Alison Thomas was in possession of three opioid medicines (codeine,  oxycodone and oral morphine) together with a gabapentinoid (gabapentin) and also high dose temazepam, a benzodiazepine, in circumstances where she  also had chronic obstructive pulmonary disease, an extensive mental-health  history, and a documented history of prescription-medication misuse and  overdose. There was a vague history of chronic pain and I was told that as she described the individual analgesics being insufficient, new ones were added.  These are the features that national guidance identifies as substantially  increasing the risk of fatal respiratory depression from the combined use of  central nervous system depressants, and compromised respiratory function is  expressly recognised by the MHRA as a heightened-risk factor. The evidence  disclosed no mechanism — whether at the point of prescribing, dispensing or  medication review — by which the concurrent supply of multiple such  medicines to a patient presenting this risk profile would be identified and  reviewed. The existing policy was inadequate and 10 years old. There is a risk  that future deaths could occur if patients with this combination of medication  and risk factors are not systematically identified and reviewed.