Irene Pearson
19 Jan 2016 · Coroner John Pollard · Manchester (South)
The coroner's concerns
1. hot bath while wearing patch
“The package leaflet of advice on the use of Matrifen is very extensive running to several pages of closely printed words. It is not until half way down the eighth page (and then contained in the middle of a 4”
2. prolonged hot bath
“Even when the said warning phrase is reached in the leaflet, it then refers to”
3. bath removal method
“heard evidence that the Macmillan Nurses had advised the deceased to take a bath when preparing to remove the 'exhausted' patch so as to aid removal. The toxicologist pointed out that even when due for change, the patch contains (and therefore can release) a very considerable level of the drug. The advice to use this method of removal would therefore seem to be inherently potentially”
4. lack of coordination in opiate prescription
“| was told that the Macmillan Nurses will prescribe additional opiate pain- control, but there seemed little or no liaison with the GP Practice as to the regulation of this”
5. incomplete electronic records
“The GP [name redacted] electronic notes of the attendances upon the patient were unclear and there appeared to be discrepancies between what was noted as prescribed by way of opiate patches, and what the patient actually had in her possession. The notes were on occasions 'scanty' in detail and the doctor giving evidence accepted this and told me that this was because they, as doctors, are limited to ten-minute appointments and they do not always have time properly to”
6. inadequate report to coroner
“When HM Coroner asks for a full report of the care of the patient from the General Practitioner, it is insufficient (as in this case), for the practice simply to photocopy part of the patient's records.”