Helen Spicer · Prevention of Future Deaths report

On 8th February 2019 I commenced an investigation into the death of 43 year old Helen Spicer. The investigation concluded at the end of the inquest on 16th April 2021. The conclusion of the inquest was as follows

• Drug Related Death

The four statutory questions – who, how, when and where were answered as follows

• Helen Louise SPICER died on 4 October 2018 at Royal Cornwall Hospital Truro from an unintentional overdose of prescription morphine against a background of opiate dependency following treatment of chronic pain due to fibromyalgia.

The medical cause of death was recorded as

• 1a acute opioid toxicity with high tolerance
• 1b fibromyalgia with long term opioid requirement
• II Poorly controlled type 2 diabetes with established end organ damage and fatty liver

Helen was admitted to Royal Cornwall Hospital Truro on 1st October 2018 with with diarrhoea and vomiting. Helen’s regular medications on admission included oral morphine on as a required basis. Helen was in pain throughout her admission and received morphine on a controlled and limited basis. The findings of fact included the following.

• Sometime after her admission on 1st October 2018 Helen acquired ████████ oramorph, without the knowledge of the medical team that were treating Helen.
• These ████████ of oramorph were lawfully dispensed on 2nd October 2018 following the presentation of a prescription issued to Helen.
• Helen consumed ███████████████████ during her admission prior to her death.
• The toxicology revealed that Helen consumed a significant quantity of oramorph after midnight on 4th October 2021, sufficient to cause her death at 5am that same morning.
• The investigation and inquest were unable to ascertain who collected that morphine from the chemist on 2nd October 2018. This is because there are no requirements in relation to the dispensing of liquid morphine as regards the need for the prescription to be signed for on collection.
• The Misuse of Drugs Regulations SI 2001 No.3998 sets out ‘Regimes of Control’ by dividing controlled drugs into 5 schedules in descending order of control, the most stringent controls applying to schedule 1 (Pharmacy and Medicines Law pg.215). Depending on the preparation, the same drug might be classified in more than one schedule. Morphine is classed as a Schedule 2 controlled drug for almost all preparations (injections, capsules, tablets, suppositories, granules and concentrated oral solution), however the ████████ morphine sulphate oral solution is classified as a schedule 5 controlled drug (BNF 78 page 465). Schedule 5 preparations are deemed as having negligible risk of abuse. There are no restrictions on the import, export, possession or administration of these preparations, and safe custody requirements do not apply to them (including the need for them to be signed for when collecting from a community pharmacy) (Pharmacy and Medicines Law pg.218). This is despite a ██████████████████ morphine sulphate oral solution (schedule 5) containing the same quantity of morphine ███████████████████of morphine sulphate █████████ (schedule 2).
• There is a risk of abuse of oral morphine.

The absence of restrictions on the import, export, possession or administration of oral morphine, and the fact that safe custody requirements do not apply to them, including the need for them to be signed for when collecting from a community pharmacy.