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Investigation and inquest
On the 21/7/2017 I commenced an investigation into the death of Jonathan EARP.
The investigation concluded at the end of the inquest on 25/4/18.
The conclusion of the inquest was a Drug Related Death.
The medical cause of death was determined to be:
1a The combined toxic effects of Alcohol, Diazepam, Pregabalin, Fentanyl, cocaine, Zopiclone, Mirtazepine and Morphine
Circumstances of the death
Jonathan Earp died at 08:15 on 10/7/17 at Gloucester Royal Hospital from the effects of prescribed and non-prescribed drugs
Coroner’s concerns
I 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 "unsent" 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.
I 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
Information checked against the published report and official responses