June Lilian Rose · Prevention of Future Deaths report

In this instance I am writing a report following the inquest into the death Mrs June Rose who died at her home address in Eltham, London on 14 August 2012. The inquest was heard on 28 April 2014 at the Inner London Southwark’s Court without a jury. Mrs Rose had been bed bound for several years before her death and her health was gradually deteriorating. Mrs Rose developed bed sore and was prescribed morphine sulphate using oral solution 5mg twice a day for pain relief. On 6 August 2012 Mrs Rose was prescribed fentanyl patches by ████████ from The Mound Medical Centre delivering 100mcg/hr in error and equivalent to 360mg of morphine per 24 hours not having appreciated its morphine sulphate equivalent.* The patch was applied on 6 August 2012 and replaced 3 days later as instructed with another patch. However, this second patch was removed later that same day by a member of the Palliative Care Team when the error was discovered. Although Mrs Rose continued to deteriorate she did not die until some days later at her home address. The pathologist gave as the cause of death as:

Ia. Bilateral pneumonia
Ib. Alzheimer’s disease

II. Fentanyl toxicity.

During the course of the inquest it became apparent, that although the overdose of morphine administered by way of the fentanyl patches did not directly cause Mrs Rose’s death, I accepted the pathologist’s evidence that:
“The drug would have had a sedating effect in an already severely ill person and was likely to have contributed towards developing a pneumonia by way of respiratory depression.”

While the prescribing doctor recognised the an error was made in prescribing the fentanyl patches at that level, it became apparent at the inquest that there appears to be little training of GPs on a national level in the prescription of this and other similar morphine based pain relief medications and consequently, a lack of familiarity with the dosage required or appropriate. I heard evidence that although this particular surgery had sought to take steps to prevent this event from reoccurring, I remain concerned that there is no mandatory training or regular refresher training on a national level in the prescribing of these kinds of drugs.

Therefore, I require to be informed as to what steps are, or will be made available or required to all GPs to familiarise themselves with the prescription of these types of pain relief medications in order to prevent a potentially and directly fatal error from occurring.