A GP surgery in Derbyshire has until August 8 to respond to a coroner’s report that found a practice pharmacist working there failed to follow a consultant psychiatrist’s recommendation that a woman who died from an overdose of prescription medicine should have had the amount she was prescribed limited.

The report was sent by Sarah Huntbach, the assistant coroner on behalf of the coroner of Derby and Derbyshire, to The Park Surgery in Heanor on June 28 this year and detailed the circumstances surrounding the death of 55-year-old Deborah Bates, who was found dead at home on June 15, 2023. In her report, Huntbach tells the surgery to outline what steps it has taken to prevent deaths occurring in future. 

An inquest into Bates’ death heard that post-mortem toxicology tests found prescribed medication at above therapeutic levels in her blood. The inquest also heard Bates, who suffered from mental health problems and chronic pain, had “taken a mixture of prescribed medication in quantities that had an enhanced sedative and respiratory depressant effect leading to her death”. Her conditions were being managed by specialist healthcare teams and her GP.

After she was admitted to hospital on April 12, 2023 following an overdose causing opiate toxicity, the consultant psychiatrist recommended the prescribing of her medication should change from seven-day intervals plus breakthrough pain medication as required to three days followed by a four-day cycle to limit the amount of prescription medication available to her at any one time and minimise her risk of an overdose.

According to Huntbach, the dispensing pharmacist “said non-blister pack three and four-day prescription could be facilitated” and “a task was sent to the practice pharmacist to discuss the case”.

However, the response of the practice pharmacist, whose name was redacted from the report, was three and four-day prescriptions may “cause confusion as double items would need to be added to the repeat prescription for each duration” and that “would result in more frequent deliveries and could cause issues." Bates’ regular prescriptions continued to be issued weekly.

Huntbach’s report said: “No further investigation or inquiries were made as to how other practices implemented this prescribing approach in a case where there are multiple medications (including controlled drugs) or whether/what safety measures are available on the computer system, to prevent/minimise the risk of the wrong prescription being requested.”

Noting Bates “had a chaotic approach to taking her medication”, Huntbach said: “Whilst limiting the amount of medication prescribed to Debra at regular intervals would have reduced the amount she had access to at any one time, it cannot be established on the evidence that it would have prevented the overdose and her death.”

However, Huntbach warned there was “a risk that future deaths could occur unless action is taken”.