Alison Thomas
8 Jul 2026 · Coroner Sean Cummings · Milton Keynes
The coroner's concerns
1. lack of safeguards for long-term combined benzodiazepine, opioid, or gabapentinoid medication
“concern. (1) At the date of [the deceased] [name redacted]' 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”
2. inadequate verification of medication requests for travel from patients with known misuse
“[the deceased]' 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”
3. absence of policy for identifying and authorising large medication requests
“At the time of [the deceased]' 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”
4. concurrent use of multiple CNS depressants in high-risk patients
“[the deceased] 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”