“| heard during the inquest that Mr Earp had been prescribed Fentanyl which was…”
Dated 8 May 2018, from the coroner for Gloucestershire. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 3 Jul 2018.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated8 May 2018
- Deadline3 Jul 2018
- Published on judiciary.uk1 Jul 2018
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Gloucestershire Hospitals NHS Foundation TrustNamed in the report as “Gloucestershire Hospitals NHS Trust” | Response publishedPublished on judiciary.uk in July 2018. |
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The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— | heard during the inquest that Mr Earp had been prescribed Fentanyl which was administered by way of transdermal patches. Mr Earp repeatedly requested additional patches however there was no evidence that all of the “unspent” patches had been returned to the nursing staff or appropriately discarded. The clinical staff believed that Mr Earp was accessing illicit drugs when he left the ward, however there was no evidence that staff considered that he may have been taking additional Fentanyl and illicit medication, and the effect this could have. | would ask that 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 Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3D) Tel 01452 305661 | Fax 01452 412618 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action.
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, 2018-0135
- 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
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