“The prescribing agency (for methadone) was unaware of the opiate overdose in November…”

The coroner’s concerns

(1) The prescribing agency (for methadone) was unaware of the opiate overdose in November 2023 and the resultant hospital admission until the inquest, and after Anna's death. (2) 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) 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) I did not find that GWH's were in any way obliged to send the discharge summary to the prescribing agency, and neither was such an omission causative or contributory to Anna's death. I did not find the prescribing regime was inappropriate, but it is possible that in other or future Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 cases, a prescribing agency could be unaware that a patient had been treated for overdose at hospital and would therefore be unable to properly review the overdose risks to its patients in an informed way, and that future deaths may occur as a result. (5) 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).

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0127

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0