Peter COLE · Prevention of Future Deaths report

On 19/09/2019 I commenced an investigation into the death of Peter COLE. Following a post mortem and toxicology analysis the cause of death provided was:
1a) Drug Overdose
1i) Ischaemic Heart Disease

The investigation concluded at the end of the inquest 27th February 2020.

Mr Cole was an older person with a diagnosis of dementia. He was in receipt of numerous prescription drugs, on repeat prescription. One of the drugs he was receiving was Tramadol, on a repeat prescription of 100 capsules per month over an extended period. The drug upon which he overdosed was Tramadol. I did not find a probable contribution to Mr Coles death as a result of the large quantity of repeat prescription drugs but heard that he had amassed a large quantity of prescription medication that he was simply not taking and was building up in his house.

As a result of concerns raised about the extent of the drugs prescribed to him, I heard evidence from an experienced Mental Health Nurse.

She outlined in her evidence that Mr Coles’ case was far from unusual. That she frequently visited patients who had amassed vast quantities of unused medication and medical supplies. Often these patients were older and with varying degrees of mental impairment. These drugs were invariably on repeat prescription and the continued need for the drugs and/or compliance with the prescribed regime was not adequately supervised. One patient had a ‘cupboard full’ of unused medication.

(1) That repeat medication is not being adequately monitored, leading to many (often older and/or mentally infirm) patients building-up dangerous quantities of prescribed medication.
(2) That the inadequate supervision of prescribed (repeat) medication is so widespread that the consequent waste of resources has an adverse impact on the overall provision of healthcare.
(3)