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recurance

Matthew Fitten

7 Dec 2019 · Coroner Nigel Parsley · Suffolk

The coroner's concerns

  1. 1. inadequate methadone dosing

    “During the evidence it was heard that at the start of the Covid19 pandemic PHE guidance was issued to Turning Point (the Suffolk Recovery Network) that individuals on opiate replacement treatment (Methadone) should be moved off short term (daily or tri-weekly) prescription collections to longer term ones”
  2. 2. unattended overdose

    “Fitten was found deceased on the 17th April 2020 at his home address of , Haverhill in Suffolk.”
  3. 3. methadone toxicity

    “Toxicology analysis identified a toxic quantity of a medication called Methadone in [the deceased]'s blood at the time of [name redacted] death”
  4. 4. changed prescription frequency

    “[the deceased] received his Methadone prescription from Turning Point and prior to the Covid19 pandemic lockdown was prescribed this drug three times per week in daily dosage bottles”
  5. 5. lack of measuring device

    “The doctor who made the changes to the prescription stipulated that [the deceased]'s dose must be in single daily dosage bottles. [the deceased] had a secure store in his home and was used to taking his Methadone from single daily dosage bottles”
  6. 6. inadequate dose measurement

    “Evidence produced by [name redacted] father during the inquest itself, clearly showed that [the deceased] had been issued three bottles of Methadone to cover the 14-day period. These bottles contained 100ml, 156ml and 500ml of Methadone respectively”

Responses

2020-0275-Response-from-Haverhill-Pharmacy-Redacted.pdf ↗· General Pharmaceutical Council and Haverhill Pharmacy

2020-0275-Response-from-Public-Health-England-Redacted.pdf ↗· UK Health Security Agency

Stated action

“Please do not hesitate to contact PHE should we be of any further assistance in this matter.”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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