A Derbyshire authority has been told to take action to prevent future deaths
09:54, 12 Mar 2026Updated 12:43, 12 Mar 2026
An inquest took place earlier this month(Image: Derby Telegraph / Ian Hodgkinson Picture It)
The NHS has been urged to take action after a woman with chronic pain died from a drug overdose.
Wendy Boddington was found dead at her home by friends who went to check on her on March 24, 2025.
The 56-year-old was found with two drug patches on her body, rather than the single patch she had been prescribed, and a post-mortem examination found that she had had a high level of the drug in her system, recognised to be in the fatal range.
She had also been prescribed codeine, something which senior coroner for the Derby and Derbyshire area, Peter Nieto, said would have added to the toxicity of the other drug.
Ms Boddington had been prescribed those medications for chronic pain since 2011, following an accident and the amputation of her arm.
At an inquest on March 2 this year, the court heard that there is now awareness of the risks of long-term prescription of opiates and opioids.
These risks include tolerance and dependence, and guidance has been issued to medical practitioners over time as understanding has increased.
The drug patches was prescribed by a GP at Ms Boddington’s GP practice in 2011 after she said other pain relief was ineffective.
The dose was increased over a short period, but at that time, GP awareness of the complications was more limited.
In 2014 and 2015, GPs at the practice had attempted to address Ms Boddington’s level of opiate and opioid medication, although she was not in agreement.
Ms Boddington had annual medication reviews, and on the evidence, there were no clear plans to address this after 2015, described as missed opportunities over a nine to ten-year period.
The court heard there was also a missed opportunity for the specialist hospital pain clinic to raise the prescription with the GP practice in 2021.
Coroner Neito said it is often the case that opiate and opioid reduction or stoppage can be difficult, and that Ms Boddington had expressed objections.
There was no positive evidence that she had placed two patches on herself to deliberately harm herself, and it is noted that she had fallen and injured her ankle just days before her death, and that she was probably experiencing increased pain because of that.
Speaking on his concerns following his investigation into the death, Mr Nieto said: “During the course of the investigation, my inquiries revealed matters giving rise to concern.
“In my opinion, there is a risk that future deaths could occur unless action is taken.
“The context for my concerns is the well-recognised situation of long-term prescription of opiate and opioid medications, often at high doses, for chronic pain. It is now recognised that such prescribing will usually cause other health problems, including dependence and tolerance, and over time becomes limited in controlling pain.
“Whilst current guidance is against such prescribing, there are many people who have been taking these medications for a long time for whom stopping or reducing the medications is very challenging.
“Use of those medications carries the risk of accidental or deliberate overdose and death.”
Ms Boddington’s inquest heard that her GP practice has initiated a targeted programme to identify patients who have been receiving long-term prescriptions of opiate and opioid medications and engage them in a focused review to agree on a planned reduction, stoppage, or substitution of those medications.
Relatedly, the practice has introduced a number of measures to try to avoid patients being inappropriately prescribed these medications for chronic pain in the first place.
In evidence, the GP partner stated that he was unaware of other GP practices in the Derbyshire area undertaking similar programmes.
The inquest also heard that there are no specialist services for patients who have developed dependence on opiates and opioids, and that substance misuse services will only work with people with non-prescribed drug issues.
The inquest heard anecdotal evidence that NHS England may be pursuing relevant initiatives, but the details and extent of these were “unclear”, the coroner added.
“My specific concern is that there appears to be a significant number of people who are being prescribed opiate and opioid medications for chronic pain, often at high doses and for long periods, but may not be receiving support to reduce, stop, or substitute those medications,” he continued.
“It appears to me that the ICB (Integrated Care Board) is in a position to consider this problem and potential remedies on a regional basis, and feed into national strategies.
“In my opinion, action should be taken to prevent future deaths and I believe your organisation has the power to take such action.”
Derby and Derbyshire’s Integrated Care Board is under a duty to respond to this report within 56 days, namely by April 28, 2026.
Derbyshire Live contacted Derby and Derbyshire ICB for comment following the publication of the report.
A spokesperson said: “We extend our sincere sympathies to the family and friends of Wendy Boddington following their tragic loss.
“We will consider the findings of the Prevention of Future Deaths report carefully and reflect on any lessons identified.”