Coroner highlights the importance of robust monitoring of patients taking hazardous medicines

The PDA has identified another Coroner’s Regulation 28 report which includes important points for all prescribers.

Sat 30th January 2021 The PDA

This case involved a patient with a history of chronic liver disease and opiate dependence. The patient had received repeat prescriptions for codeine phosphate to treat abdominal pain secondary to liver problems.

The patient self-referred to Turning Point for support with opiate dependency in January 2020. Despite noting the existence of chronic liver disease in the patient’s notes and contacting the patient’s GP to ask whether there were any recent blood test results, the prescriber went on to initiate methadone treatment in the absence of a response from the GP and without requesting LFTs themselves.

The patient was commenced on 30ml daily of methadone increasing to 60ml daily over several days. The patient failed to attend any further appointment, although a follow-up prescription was collected on her behalf. The patient was found dead in February 2020 with the cause of death attributed to the accumulation of methadone which she was unable to eliminate effectively due to impaired liver function.

Key learning points

  • Check for conditions which might affect drug handling before you prescribe for an unfamiliar patient.
  • Take potentially impaired drug handling into account when prescribing and familiarise yourself with key drugs where caution is required.
  • Make sure patients with impaired renal or liver function, or those on high-risk medicines which can cause impairment, have regular blood tests and that those tests are interpreted and acted upon where necessary. Many of the required tests can be found in the PINCER suite of searches and form part of measures in primary care to improve medicines safety.

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