Mr. Kurnathy · Prevention of Future Deaths report

On the 14th August 2024, I commenced an investigation into the death of Mr. Kurnathy. At the inquest into his death on the 11th November 2024 I found that he died from an acute cardiac episode, contributed to by fentanyl and morphine toxicity.

My findings at the inquest were as follows –

The deceased was 51 years old at the time of his death. He had a number of chronic health conditions including ischaemic heart disease and cardiomyopathy. On the 19th April 2024 an ECG indicated that his left ventricular function was less than 25% ejection. He also suffered from chronic pain as a result of long standing colorectal issues and was under the care of a consultant. He was prescribed fentanyl by his GP in the dose of 1 25mg patch per 72 hours. He was also prescribed morphine sulphate.

On the morning of the 9th May 2024, the deceased was found unresponsive in the kitchen at his home address. Paramedics attended and pronounced life to be extinct. Autopsy confirmed the presence of an acute left ventricular failure. Examination revealed the presence of 4 fentanyl patches on the upper back of the deceased, which was in excess of the amount he was prescribed. Toxicology reported the presence of fentanyl and morphine in levels associated with fatalities.

There is no evidence that the deceased intended to take his own life. It is not clear whether his application of the patches was a mistake or a response to the level of pain he was experiencing. However, I find the excessive, even if accidental use of these strong opiates would have had a consequent effect on his already failing heart and is likely to contributed to his death from acute left ventricular failure.

I heard evidence during the inquest from ████████ of the practice. ████████'s evidence was that Mr. Chetty was being prescribed fentanyl patches through the practice for chronic pain. The evidence was that Mr. Chetty managed his own medication at home and was assessed to have capacity to do so.

His last prescription was for 10 patches as 1 x 25mg patch per 72 hours. ████████'s evidence was that this prescription should last Mr Chetty a month and was the maximum amount of this controlled drug that a patient could be prescribed at any one time.

On the 17th April 2024 Mr. Chetty was seen by his Consultant at Salford Royal Hospital. A letter sent to Brinnington Surgery by ████████ reported that Mr. Chetty had disclosed using multiple fentanyl patches in order to address his current levels of pain.

This report of excessive fentanyl use outside of the prescribed regime was not identified by the Surgery upon receipt of the letter and did not trigger a medication review for Mr Chetty.

I am concerned that the correspondence triage did not identify this excessive use of a controlled drug which is known to cause fatalities if abused.

I am further concerned that there are no specific policies or procedures within the Surgery to flag up or review concerns around fentanyl abuse. As a known recipient of this and other strong opiate medication, all correspondence received by the surgery relating to Mr. Chetty’s treatment and care had the potential to reveal important information about his ability to self-manage his medication.