15 Sep 2016 Philip Richard David BREATNACH · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 8 Excessive quantities of Dihydrocodeine prescribed View source Unrestricted online applications for medications View source Prescribing Dihydrocodeine for migraine View source Failure to prescribe safe Dihydrocodeine dosing instructions View source Failure to contact the patient’s GP to verify medication application answers View source Failure to account for the potential diversion of Dihydrocodeine View source Failure to thoroughly check online medication application forms View source Failure to assess a patient in person before prescribing Dihydrocodeine View source See 5 more concerns
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Philip Richard David BREATNACH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Philip Richard David Breatnach's circumstances are referred to in the Record of Inquest. The concerns relate to online applications for medication, inadequate checking of answers and failure to contact his GP, and the prescribing of Dihydrocodeine by a prescriber who had not seen him, including concerns about the quantity, suitability for migraine, and dosing instructions. The inquest concluded with a finding of MISADVENTURE (DEPENDENCE ON DRUGS).
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to H & R Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Excessive quantities of Dihydrocodeine prescribed
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true.
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive .
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed.
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to H & R Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Unrestricted online applications for medications
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true.
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive.
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed.
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to H & R Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Prescribing Dihydrocodeine for migraine
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true.
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive.
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed.
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to H & R Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe safe Dihydrocodeine dosing instructions
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true.
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive.
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required . The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed .
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to H & R Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the patient’s GP to verify medication application answers
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true .
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive.
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed.
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to H & R Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to account for the potential diversion of Dihydrocodeine
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true.
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive.
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed.
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency . The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to H & R Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to thoroughly check online medication application forms
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked , allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true.
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive.
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed.
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to H & R Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to assess a patient in person before prescribing Dihydrocodeine
Wider context from the report “(1) Mr Breatnach (and anybody else) is able to apply online for medications
(2) That applying online, if the application form is not thoroughly checked, allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach’s GP to find out if the answers that he gave were true.
(4) Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice.
(5) The amount of Dihydrocodeine prescribed appears to be excessive.
(6) I understand from the evidence that I heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication.
(7) The instructions were that the Dihydrocodeine should be taken every four to six hours as required. The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is I heard not the way Dihydrocodeine should be prescribed.
(8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency. The medication came in three packets – one containing one hundred tablets and the other two containing twenty eight tablets each. The two packets containing twenty eight tablets each were never found and this raises the possibility that Mr Breatnach was able to sell them, although I have no evidence that he did.
(9) This way of prescribing completely undermines the diligent and careful GP’s efforts to control this man’s medication over use.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations