Louise Jones
12 Jun 2024 · Coroner Guy Davies · Cornwall and the Isles of Scilly
The coroner's concerns
1. lack of opioid treatment agreement
“There was no agreement with [the deceased] before starting opioids, regarding a treatment strategy and plan for end of treatment as recommended by NICE. There was no practice policy requiring such an agreement.”
2. long term opioid prescription without policy
“There was no policy in place at the GP practice regarding long term (longer than 3 months) prescription of opioids.”
3. no warning flags at 3-month morphine stage
“There were no warning flags in place at the practice at the 3-month stage of morphine prescription, to reflect the MHRA/CHM advice referred to in NICE guidance, regarding the increased risk of addiction beyond this period.”
4. no policy on co-prescription of opioids and benzodiazepines
“There was no policy in place at the GP practice regarding co-prescription of opioids and benzodiazepines, to reflect the MHRA/CHM advice referred to in NICE guidance regarding the increased risk of respiratory depression and death.”