Jonathan Earp
8 May 2018 · Coroner Caroline Saunders · Gloucestershire
The coroner's concerns
1. unspent transdermal fentanyl patches
“Mr [name redacted] repeatedly requested additional patches however there was no evidence that all of the”
2. lack of guidance on managing prescribed and illicit drug administration
“consideration is given to providing staff with guidance on how to manage the administration and provision of prescribed drugs when the patient is also accessing non- prescribed potentially illicit drugs”
3. assumption of illicit drug use without evidence
“clinical staff believed that Mr [name redacted] was accessing illicit drugs when he left the ward”