Matthew William Thomas Power · Prevention of Future Deaths report

An inquest into the death of Matthew William Thomas Power was opened on 29 September 2022 and resumed and concluded on 14 June 2023.

The medical cause of death given was:

1a. Mixed Drug Toxicity.

And I determined that

Matthew William Thomas POWER died on 17 June 2022 at 01:30 hours at a house in Redhill, Surrey having taken illicit and prescribed drugs over the previous 36 hours resulting in his death from mixed drug toxicity.

My conclusion was this was a drug related death

Mr Power was a 33 year old man living in supported accommodation. He had a history of mental health issues and had been diagnosed with Dissocial Personality Disorder. He also had a history of drug and alcohol abuse dating back to his teenage years. He had been known to take impulsive overdoses of drugs including prescription drugs (████████).

On the afternoon of 15 June 2022, Mr Power visited friends in the Redhill area and with them bought and took drugs throughout the next 36 hours until his death in the early hours of 17 June 2023. Toxicology revealed a very high level of cocaine (potentially lethal in itself). It also showed heroin, methadone (which was not prescribed) and codeine at levels that any of those drugs could have been lethal on its own, but that each opioid was likely to have increased the toxic effects of the other. The codeine was from ingestion of co-codamol.

Apart from his mental health medication, Mr Power was prescribed co-codamol for pain relief. He had been prescribed this medication both by his current (since 2020) and previous GPs. It was latterly prescribed ████████ █████████████████████████ because of stockpiling concerns; he had frequently requested co-codamol. In evidence it was accepted that there had been errors in prescribing so that on 14 June 2022 Mr Power collected ███ co-codamol tablets from a local chemist (but not his usual chemist) whilst still receiving his regular prescriptions █████████.

1. The GP practice uses EMIS for patient records and prescribing. From the evidence it appears that when one doctor ends a repeat prescription on EMIS, it remains in the 'pending' Medication Management box of the doctor to whom it was originally sent. Creating the risk, as in this case, that as a pending prescription it is actioned and issued instead of cancelled.

2. I heard evidence that the EMIS system appears to group prescriptions into the amount prescribed rather than simply recording when a prescription is issued. In this case there were different entries grouped as 100 tablets, 50 tablets, 30 tablets, and 24 tablets. Consequently, it was not clear to the duty doctor that the most recent prescriptions for co-codamol had been for a shorter course of only █ tablets and as a result █ tablets of co-codamol were prescribed and issued.

3. Evidence was given by the GP practice that to interrogate the EMIS system in order to ascertain what had actually been prescribed, issued and when, was a challenging task; it had taken 3 GPs and the in-house pharmacist to conduct the review.