Paul Clark
16 Oct 2024 · Coroner Alison Mutch · Manchester South
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. opioid relapse due to GP prescribing
“The inquest heard evidence that [the deceased] had previously been addicted to heroin. He had been successful in treating his opioid addiction and had remained opioid free for many years. His previous problems with opioids and the risks of opioids for him were well documented within his medical notes. However despite the risks opioid painkillers presented to him he had been started in primary care on opioid based painkillers for reported pain. He had become addicted to them and took them at”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“However despite the risks opioid painkillers presented to him he had been started in primary care on opioid based painkillers for reported pain. He had become addicted to them and took them at increasing levels topping them up with non-prescribed opioids.”
Later report
“[the deceased] had been prescribed opiates for many years despite the risks associated with long term opiate prescribing. The evidence before the inquest was that there had been very limited attempts to review the long term prescribing of opiates to her.”
Responses
2024-0558-Response-from-GMIC.pdf ↗· Greater Manchester Integrated Care Board
Stated action
“Archwood Medical Practice have undertaken an audit of their patient records to identify all patients with a history of drug addiction. A 'pop up' alert will be added to each identified record to ensure that anyone consulting with a patient within this cohort is immediately aware of the history and can therefore consider this history within their clinical decision making.”
2024-0558-Response-from-RCGP.pdf ↗· Greater Manchester Integrated Care Board
Stated action · October 2024
“We have recognised the importance of safety in repeat prescribing and the role that General Practice and Community Pharmacy have in this space. Through our Clinical Policy work we have A4 collaborated with the Royal Pharmaceutical Society and over the last year, I co-chaired a group to develop a New Repeat Prescribing Toolkit to improve safety and efficiency of repeat prescribing systems in general practices across England (the first of its kind in over 20 yrs). We launched this toolkit at our A”