Surgery overhauls drugs policy after patient overdoses

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A GP surgery in Hemel Hempstead has revised the way it prescribes drugs after a patient died of an overdose after stockpiling painkillers, an inquest heard.

Herts Coroner’s Court was told Naomi Day, 50, of Typleden Close, Hemel Hempstead, took 50 co-codamol tablets having been prescribed 400 in less than two months for back and hip pain due to an ‘error’.

Coroner Edward Thomas told the court he will be writing to practices across Herts to pass on the actions Highfield Surgery has taken following the death, which include involving doctors more in the batch prescription process.

“I was concerned about that,” he said. “Although she seemed well with you there may have been a stockpile for her to take when she felt low.”

Dr Elizabeth Craske, a GP at the surgery, said: “It was more than she should have had. It was an error that she had so many.

“We have made quite a lot of changes to our repeat prescriptions.”

Laura Owen, Naomi’s sister, asked the court why her previous addiction to alcohol and history of mental health problems were not considered by the surgery when prescribing.

“Seeing someone who is prone to addiction, I don’t really understand why this was not considered, that it was not the way to go with someone in that position,” she said.

“Is there not a process that GPs have to follow with a person in that situation?”

She added: “Having spoken to the pharmacist and shopkeepers, they had barred her from buying codeine-based products. There were lots of occasions when she approached me to buy codeine for her.”

The court heard Naomi, who was overweight and had a history of taking ‘impulsive’ overdoses, was admitted to Watford General Hospital on April 17 having taken co-codamol – a mix of codeine and paracetemol – three days earlier.

After feeling unwell she contacted her social worker Jennifer Dellow, who told the court: “She said she kept falling over and felt ill. I said keep walking round, don’t lie down and we’ll call an ambulance.”

Previously she told the court Naomi had a good sense of humour and ‘was able to laugh at herself’ and she would often go over their allotted appointment time because she enjoyed their conversations.

The court was told Naomi, a widow, took the pills after a row over the phone with a man she met in Kenya, who she saw as her husband but he had been refused a visa to come to the UK.

Mr Thomas said: “The person she fell for in Kenya couldn’t come over because of visa problems and she was not sure if she was just a meal ticket.”

Naomi was transferred to the Royal Free Hospital in London for treatment but she died of multi organ failure, with secondary causes of liver failure and drug overdose, on April 25.

Mr Thomas, recording a verdict of accidental death, said: “My view was her intention was a cry for help because she was distressed.”