Medicines management policy for high-risk drugs introduced by GP practice, following death of patient
A GP surgery has updated its prescribing policies for high-risk medications following the death of a patient who had access to multiple controlled substances. The coroner's report highlighted failures in managing long-term combined prescriptions for opioids and benzodiazepines.
Why it matters
This case underscores the critical importance of rigorous medication management protocols in primary care to prevent fatal drug interactions and misuse.
A GP surgery has implemented a medicines management and safe prescribing policy for the prescribing of high-risk medicines, including opioids, benzodiazepines and gabapentinoids, in response to the death of patient.
In a ‘ Prevention of future deaths’ (PFD) report , published on 16 September 2026, Sean Cummings, coroner for Milton Keynes, stated that Alison Rose Thomas, aged 58 years, who had chronic obstructive pulmonary disease, was found dead at home on 29 December 2025 after taking a large amount of different medications.
The coroner wrote that Thomas, who had “vague history of chronic pain”, was usually prescribed codeine tablets on a weekly basis, alongside gabapentin, oxycodone and oral morphine. She also had purchased diphenhydramine from a pharmacy, the coroner added.
According to the PFD, Thomas was found in possession of codeine, oxycodone, oral morphine, gabapentin and high-dose temazepam.
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