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A GP practice in Milton Keynes has said it has developed a “comprehensive” medicines management and safe prescribing policy following the death of a patient who took a large amount of different prescribed and over-the-counter medicines.

The Grove Surgery in Netherfield made its assurance in writing to assistant coroner Sean Cummings, whose inquest into the death of Alison Rose Thomas found she obtained about a month’s supply of codeine from her GP, as well as 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”.

In his report on July 8 this year, Cummings said 58-year-old Thomas managed to get hold of the drugs despite being restricted to weekly prescribing “because of a known risk of abuse and self-harm”.

She was found dead at her home on December 29 last year. Cummings said there was insufficient evidence to reach a conclusion of suicide.

The inquest heard Thomas, who had chronic obstructive pulmonary disease and an extensive mental health history, also got hold of diphenhydramine which, Cummings noted, “is available to purchase from pharmacies”, as well as high dose temazepam. 

“She was known to abuse prescription medications and had taken overdoses in the past. She had an extensive mental health history,” the report said.

It concluded the practice’s medicines management policy “contained no provision addressing the safe prescribing, review, monitoring or quantity-control of long-term combined benzodiazepine, opioid, or gabapentinoid medication” at the time of Thomas’s death.

The report also said the practice “had no policy governing how requests for larger-than-usual quantities of medication for travel purposes from patients known to misuse prescription medicines were to be identified, assessed, or authorised".

“The deceased was known to the practice to misuse prescription medication and to have taken overdoses in the past,” it added. Cummings warned there was a risk of deaths in future “if patients with this combination of medication and risk factors are not systematically identified and reviewed”.

Comprehensive medicines management and safe prescribing policy

However, in its response to Cummings this month, The Grove Surgery said it “developed a comprehensive medicines management and safe prescribing policy" on August 19 which will be “reviewed annually”.

“The policy is available within the shared drive of the practice which is accessible to all staff,” the practice said. “Staff have been informed of this new development.”

Insisting those reviews will be led by its prescribing lead and supported by the practice pharmacist, The Grove Surgery added: “There will be a quarterly meeting to discuss controlled drugs which will be implemented in October 2026. This is in addition to discussions which are normally undertaken concerning any medication queries in the monthly clinical meetings.”

The Grove Surgery promised to update its policy “when significant changes occur in the local or national guidance” and insisted its prescribing lead will oversee its implementation, co-ordinate prescribing audits, identify trends, review high-risk prescribing and monitor controlled-drug prescribing.

High-risk medication requires enhanced scrutiny

The practice also said the prescribing lead will disseminate guidance, liaise with medicines-optimisation teams, review Medicines and Healthcare products Regulatory Agency alerts and escalate significant prescribing risks, while working closely with the practice pharmacist.

The Grove Surgery told Cummings it had revised its policy for patients who request medicines “earlier than expected especially in relation to travel”, which will be reviewed annually.

“The policy deals with prescription of both routine and high-risk medication, specifying that the high-risk medication requires enhanced scrutiny,” the practice said.

“The policy also addresses the issue of patients who have an existing prescribing restriction; the default position is that the restriction stays in place until a clinician is satisfied that there is a clinical reason to alter it.”

Insisting “travel alone is not a sufficient reason to alter the restriction”, the Grove Surgery added: “The policy also deals with verification of travel, noting that verification may be necessary if it is proportionate to the risk that the particular medication poses.”

Under the policy, the practice added, clinicians will carry out “a risk assessment, consider verification of the reason for a higher quantity, document their rationale and what safeguards have been put in place”.

The Grove Surgery stressed the policy “specifically deals with opioid and benzodiazepines management, dictating that long-term therapy should be reviewed regularly every three months, depending on clinical indication”.

“The review should encompass issues such as indication, dose escalation, dependence, withdrawal, sedation and concurrent medicines,” it added.

The Grove Surgery told Cummings it hoped its response “provides assurance” that it is “committed to learning from this inquest to improve the care of patients at the practice and to mitigate any risk of future deaths”.