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.
The coroner noted that Thomas’s codeine was deliberately prescribed weekly because of a known risk of misuse and self-harm. However, Thomas had told staff that she was planning to travel and “was able to obtain approximately a month’s supply of codeine, together with gabapentin, oxycodone and oral morphine (Oramorph), on the strength of an unverified assertion that she was to travel to France for a month over the holiday period”, the coroner added.
Cummings also wrote that, at the date of Thomas’s death, the patient’s GP surgery operated a medicines management policy, but it did not specifically address long-term combined benzodiazepine, opioid or gabapentinoid medication — despite extensive national guidance, including Medicines and Healthcare products Regulatory Agency drug safety updates, which address the risk of fatal respiratory depression from opioids and gabapentinoids.
In a response to the coroner’s concerns, issued on 9 September 2026, The Grove Surgery said that its updated policy — implemented on 19 August 2026 — states that when prescribing high-risk medicines, prescribers must assess a risk-based, specific set of factors, which include respiratory risk, concurrent central nervous system depressants and substance-misuse history, where clinically relevant.
The Grove Surgery added: “The policy specifically addresses the combined prescribing of opioid, benzodiazepine and gabapentinoid medication.
“Where all three classes are prescribed concurrently, the policy requires that the patient undergoes a documented medication review (unless there already is a clearly documented specialist-led rationale) and for the patient to have concurrent review arrangements in place.
“Even when a patient is taking one or two of these medications, a review must occur prior to any new prescription being issued.”
Patients on long-term opioid or benzodiazepine therapy must undergo reviews every three months, it continued. The Grove Surgery also said that it will consider implementing measures including dose reduction and deprescribing, psychological support, pain-management services and substance-use services.