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A patient, whose condition and behaviour had been challenging, presented a number of prescriptions her pharmacist calling for a variety of pain relief drugs. The pharmacist noted that the prescriptions were for similar items from two different doctors but the patient explained that she had changed surgeries and why she needed all the items from all the prescriptions. The pharmacist was not aware that the GPs from different surgeries had not contacted each other so dispensed a number of the prescribed items.

The patient was later found dead from an overdose. Quantities of other medications were found in her home and analysis showed that there were a number of drugs in her body. At the subsequent inquest, where the pharmacist also gave evidence, the coroner’s verdict was death by misadventure. He was satisfied that there were appropriate SOPs in place and that there had been an appropriate investigation to address any issues by the company. No action was taken against the pharmacist.