Michael Lobban · Prevention of Future Deaths report

On Tuesday 10th September 2019 Russell Caller, Assistant Coroner, heard the inquest of Michael Lobban who was found dead at his home at ████████ on Monday 23rd October 2017

Medical Cause of Death

1 (a) Mixed Drug Consumption

How, when and where and in what circumstances the deceased came by his death:

Michael Lobban was on a prescription of 5mg Methadone tablets and was required to pick up his prescription from Boots, Queensway London Branch on a regular basis. Michael Lobban was known to the staff at this Boots branch. On Thursday 19th October 2017 Michael Lobban picked up 68 x 5mg Methadone tablets in accordance with his prescription. The following Thursday 26th October 2017 during a Controlled Drug Running Balance audit check by Boots, Queensway Branch there was a disparity in the numbers of Methadone tablets. It transpires there were 51x 5mg methadone tablets missing.

On the Monday prior to this audit check on Monday 23rd October 2017 ( 3 days before Boots discovered the disparity of 51 x 5mg of methadone tablets) Michael Lobban was found dead in his home at 31c Talbot Road London W2 5JG with, inter alia, an excessive amount of methadone in his blood ( 0.56 ug/ml in his blood) which amounts to a significant overdose of methadone.

There were other drugs found in Michael Lobban’s body in the toxicology report taken after death.

Conclusion as to the death:

Drug Related

For many years Michael Lobban had been suffering from serious mental health issues and had been under the Drug and Alcohol Well-being Service (DAWS) for a number of years.. He suffered from drug dependency and mental illness and had periods of overdosing causing self-harm and there had been threats of suicide.

Michael Lobban was on a prescription of 5mg Methadone tablets and was required to pick up his prescription from Boots, Queensway London Branch on a regular basis. Michael Lobban was known to the staff at this Boots branch. On Thursday 19th October 2017 Michael Lobban picked up 68 x 5mg Methadone tablets in accordance with his prescription. On the following Thursday 26th October 2017 during a Controlled Drug Running Balance audit check by Boots, Queensway Branch there was a disparity in the numbers of Methadone tablets. It transpires there were 51x 5mg methadone tablets missing.

On the Monday prior to the audit check on Monday 23rd October 2017 ( 3 days before Boots discovered the disparity of 51 x 5 mg of methadone tablets) Michael Lobban was found dead in his home with, inter alia, an excessive amount of methadone in his blood ( 0.56 ug/ml in his blood) which amounts to a significant overdose of methadone.

There were other drugs found in Michael Lobban’s body in the toxicology report taken after death.

1. The investigation carried out by The Boots Company PLC into the disparity of Methadone tablets on this occasion was slow and efforts to contact patients who were regular prescription users of methadone was not fully followed through.

2. The audit checking of controlled drugs by The Boots Company PLC is not robust in that there is no double check in place in relation to the audit checking procedure followed by Boots.

3. There appears to be no physical check of the contents of prescription boxes when carrying out the audit of schedule 2 controlled drugs.

4. The General Pharmaceutical Council (“The Council”) being the Regulator of Pharmaceutical industry in England and Wales does not have any reporting requirements for pharmacies when discovering a discrepancy in schedule 2 controlled drugs. Moreover there appear to be no investigative powers by The Council where it discovers a disparity of these controlled drugs and as a consequence there are no sanctions in circumstances where pharmacies have mislaid drugs during the course of their handling of controlled drugs.