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Prevention Of Future Deaths Report Issued Following Community Pharmacy Error

It’s not very common for Coronial Prevention of Future Deaths Reports, or PFDs, to specifically relate to actions in community pharmacy.  However, one published this week does precisely that. The case arises from the death of a young man, Mr MF, following a Methadone overdose in April 2020.

At the start of the COVID19 pandemic in 2020, Public Health England advised that individuals on opiate replacement treatment/Methadone should be moved from short term (daily or tri-weekly) prescription collections to longer intervals.  In the case of Mr MF, his Methadone collection was changed from three times per week to fortnightly.  His prescribing doctor stipulated that Mr MF’s dose was to be provided to him in single, daily dosage bottles each containing 54ml of Methadone.

Unfortunately, Mr MF’s community pharmacy dispensed his Methadone in three large bottles, each containing as much as 500ml of Methadone, and did not provide a measuring jug.  Mr MF was found dead shortly after collecting his prescription and his cause of death was recorded as Methadone toxicity.

As Mr MF had been doing well in his recovery and there was no indication of any intention to die by suicide, the Coroner concluded that, due to the lack of a measuring jug, Mr MF guessed his first dose from the large Methadone bottles provided to him and accidentally overdosed.

The Coroner found that, had Mr MF been given daily dose bottles of Methadone as prescribed, or a measuring jug and instructions on how to use it, on balance of probability his death would not have occurred.

Under the Coroners and Justice Act 2009, coroners are obliged to report about deaths with a view to preventing future deaths.  These reports are known as Prevention of Future Deaths Reports, or PFDs.  As a result of Mr MF’s death, the Coroner has issued a PFD to Public Health England, the General Pharmaceutical Council and the individual community pharmacy which dispensed Mr MF’s Methadone.

As the Chief Coroner’s guidance makes clear, PFDs are “not intended as a punishment; they are made for the benefit of the public” and are “intended to improve public health, welfare and safety”.  However, being the recipient of a PFD is a serious matter.  Almost all PFDs are published by the Chief Coroner and become a matter of public record.  Further, the recipient of a PFD has a legal obligation to respond to the Corner within 56 days providing either (a) details of all action taken, or proposed to be taken, and a timetable for action, or (b) a cogent explanation as to why no action is proposed.

I will update this blog with the responses provided by the General Pharmaceutical Council and other PFD recipients once they are available.  The full published PFD is linked here.

UPDATE – Both Public Health England and the individual pharmacy have now provided their replies to the PFD.  The General Pharmaceutical Council does not appear to have replied.

Essentially, the pharmacy is unable to confirm or deny whether Mr MF’s Methadone was provided in individual or large bottles.

The pharmacy says that it “always supplies Methadone in individual bottles” and that, if the supply to Mr MF was made in individual bottles, “this was in line with the pharmacy’s normal way of work”.

On the other hand, “if supply was not made in individual bottles…this is not the normal practice of the pharmacy”.  The pharmacy asserts that it “always ensures safety and wellbeing of patients” but “April 2020 was an unprecedented time and all pharmacies were dealing with staff issues, supply issues and abuse from patients towards NHS staff. All these factors may have made the pharmacy supply the methadone not in individual bottles”.

The full replies can be viewed here.

It is important to bear in mind that the pharmacy’s reply is now a matter of permanent public record and it is strongly advisable for any pharmacy to seek advice from its insurer or solicitor prior to submitting a response to a PFD.

Published inClinical Negligence ClaimsInquestsPharmacists