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When Dr K, a GP partner, arrived at a coroner’s inquest she was surprised to find that her practice had been identified as an Interested Person (IP) in the case. Having previously attended inquests as a witness of fact, she was somewhat alarmed when the coroner adjourned the process to allow the practice to be legally represented.
She immediately contacted Medical Protection.
Following her initial reassuring telephone call with Medical Protection, Dr K sent in the required documents which showed that the inquest was being held due to a drug-related death. Dr K initially believed this did not relate to the practice as the patient, Ms A, had been on the medication for a number of years. She had also been an inpatient in hospital several times over the same period with no recommendations to stop the drugs.
The inquest was adjourned for eight weeks which allowed Medical Protection to arrange legal representation on behalf of the partners, who were all Medical Protection members.
Once the documents had been reviewed, it became apparent that the initial report for the coroner had been written without the input of a defence organisation. It contained a printout of the medical records and a brief covering letter.
The family of Ms A had raised many concerns over her medication with opioids and benzodiazepines. They felt that Ms A had not been adequately counselled on the potential risks and therefore had probably been taking more medication than she had been prescribed.
Ms A had a history of anxiety following abuse by a partner. She had been on benzodiazepines to assist with sleep and had a recorded diagnosis of insomnia. She had been on opioid medication, codeine phosphate, for back pain following fractures sustained as a result of physical abuse. According to the records she had been on this combination of medications for ten years.
Ms A had also been on a number of antidepressants over the same time period, including sertraline and amitriptyline; however, at the time of her death she was taking fluoxetine. She had recently been admitted to hospital and had a one-week, inpatient stay due to pneumonia. Records showed over the ten-year period she had been admitted to hospital two-to-three times per year and always discharged on the same medications.
Medical Protection reviewed the medical records of the deceased and obtained a copy of the postmortem which showed toxic levels of drug combinations. However, the records also showed clear discussions between various GPs at the practice and Ms A outlining their concerns about the medication combination she was taking. Specifically, the practice had tried to get Ms A to engage with a local pharmacist. They had also requested input from the pain team to address the same issues. However, this had not been clearly set out in the initial report for the coroner.
Several meetings were held with the doctors to explore their understanding of the patient, her medical background, the medications she was taking, and the interactions with other healthcare providers. A suggestion was made to provide a more detailed statement specifically focusing on the questions that had previously been asked by the coroner. These included:
why Ms A was on this combination of drugs
evidence of medication reviews that considered alternative medication
The benefits of undertaking a SEA were also discussed with the practice partners.
Following the advice given by Medical Protection, the practice decided to undertake the SEA and, as part of that process, it was established that a warning from the Medicines and Healthcare products Regulatory Agency (MHRA) had been issued relating specifically to opioids and benzodiazepines. These warnings had been issued nationally in 2018 and 2020 and the practice reflected on why no specific actions had been taken at the time.
The SEA process also identified that a number of patients were currently taking this specific drug combination, despite the warnings that had been issued. The practice then took steps to identify the patients and bring them in for detailed consultations to discuss the risks of the medication. Following the SEA and subsequent consultations and medication reviews the practice managed to reduce the number of patients on the medication by 75%.
The practice also put in place a number of other prescribing related changes as a result of the SEA and included this information in the updated statement for the Coroner.
Following submission of the additional report and the detailed SEA, the practice was still asked to attend the inquest as an IP, and Dr K gave evidence on behalf of the practice. Dr K was able to fully understand the concerns raised by the family and express clearly the steps that had been taken to address the medication issues with the patient and the barriers to reducing the combination she was prescribed.
She also outlined the steps the practice had taken to identify other patients taking the same medications and the positive action in stopping this medication combination safely for a significant proportion of patients.
The coroner commended the work of the GP practice, acknowledging the difficult conversations the practice had undertaken with their patients during a busy period. The coroner specifically noted that the practice’s determination to make it safer for other patients meant that any reduction in deaths would be a legacy attributed to Ms A.