Anna Burns

1. 1. unaware of opiate overdose and hospital admission

   “The prescribing agency (for methadone) was unaware of the opiate overdose in November 2023 and the resultant hospital admission until the inquest, and after [the deceased]'s death.”

2. 2. discharge summary not sent to prescribing authority

   “Whilst a discharge summary was properly sent to the (previous) GP, no such notice regarding the opiate overdose was sent to the opiate prescribing authority.”

3. 3. inappropriate prescribing without overdose history

   “Evidence was heard at the inquest that had the prescribing authority known of the opioid overdose in November 2023, they would have reviewed her case and likely would have put in place restrictive prescribing practices (such as lower or single daily doses, possibly supervised). It is also possible that they may have contacted the GP to warn them of the increased risk. Evidence was heard that not knowing of such an admission left the prescribing authority in a position of potentially approving inappropriate prescribing regimes (with risk of overdose in such cases).”

4. 4. lack of standardized notification of overdose admissions

   “It should be considered that notification to relevant parties (especially methadone prescribing authorities) regarding hospital admission for drug overdoses take place in the same manner as GP's highlighting the nature of the admission (i.e. overdose).”

No published response was found on judiciary.uk.