A Derby coroner has urged a local GP practice and community pharmacy to review their policies around issuing prescription medication over “longer bank holiday periods” after a woman was found dead on Easter Monday having taken “excessive” medication.

Margaret Feeney was found in her home on April 1 this year at the age of 78, having last been contacted two days prior. A post-mortem and toxicology examination established that she had died due to the “combined toxic effects of prescribed medication which she had taken in excess.”

“A high total morphine level suggests the potential additional taking of a morphine-based substance,” wrote senior coroner Peter Nieto, adding that there “is no reason to consider” that she had made a deliberate suicide attempt. 

Margaret was described as having a “long history” of being prescribed benzodiazepines and codeine, the latter of which she took for pain caused by diagnosed conditions. 

As she had become dependent and “was recognised to overuse” these medications, she was put on seven-day prescriptions. 

The coroner found that on Tuesday March 26 Margaret’s friend brought her to see her GP over concerns that she was “confused”. 

The GP wanted to reduce her diazepam dose and issued a new prescription, which she received on March 27. This came after she had received her usual prescribed diazepam and codeine on Monday March 25. 

The new diazepam prescription meant she had “an excess of five days of that drug”. In addition, because of the coming bank holiday she received an early prescription of codeine on March 28, giving her four days’ excess codeine.

“Clearly, given her recognised dependence and overuse, there was a real and foreseeable risk that Margaret would take excess diazepam and codeine that was available to her between March 27 and her death,” wrote the coroner. 

“In addition to the toxicological evidence, when she was found there were empty or near empty blister packs from the excess medication prescribed to her.” 

Writing to Macklin Street Surgery and Daynight Pharmacy on Macklin Street in Derby, the coroner said he was concerned there were no measures in place to prevent the issuing of excess medicines to patients at risk of intentional or unintentional overdose, “who ae ordinarily issued shorter period repeat prescriptions to reduce those risks”. 

He noted that there are particular problems around state holidays when most pharmacies are closed and said that while measures have been introduced for single day bank holidays “there are no measures relating to longer bank holiday periods” such as Easter.

“With electronic patient record and data systems it seems a reasonable presumption that suitable solutions can be identified,” he wrote.