Highland prescription drug overdose death prompts order from Scottish Public Services Ombudsman for GP practice to apologise to family
A GP medical practice has been ordered to apologise to a Highland family after their adult child died from a prescription drug overdose.
The person who died, who has not been identified, had a history of “multiple drug overdoses” and alcohol misuse, and passed away after overdosing on a type of prescription opioid that an investigation heard is “implicated in many drug-related deaths”.
The Scottish Public Service Ombudsman (SPSO) carried out the investigation into the death of the person, which it referred to only as ‘A’, after their parent questioned the medical practice’s decision to not just grant A early or additional prescriptions on request on “multiple occasions” despite their history of overdosing - but also for dishing out larger prescriptions that would last a month, instead of only a week or even a day.
The parent, known as ‘B’, also raised concerns over A being kept on by the GP surgery as a remote patient despite having moved a “significant distance away” from the practice - something the ombudsman said had influenced the decision to provide monthly prescriptions instead of smaller weekly or daily ones.
And while the ombudsman said it could not say whether these decisions had contributed to A’s death, it ruled that the practice “had not provided A with reasonable care and treatment with regard to their prescription medication”.
During the investigation the SPSO heard that A had been prescribed a number of different medicines by their GP surgery, including painkillers and depressants.
B complained that the practice “did not appropriately manage the risks of prescribing A such medication” and had “insufficient regard to A’s history of overdoses”, the SPSO said.
In its response to the investigation, the SPSO said that the practice stated that shorter prescriptions did “not necessarily prevent the hoarding of medication” and added that patient A had been kept on their books despite moving away because their nearest local GP surgery was staffed by locum doctors “lacking a familiarity with A’s situation”.
The ombudsman added: “[The practice] said that while they were aware of A’s overdoses these were often also due to alcohol or illegal drugs. The practice said that they felt A’s requests for additional medication had been genuine and that they needed to balance the risk that A would seek illicit drugs or street medication if suffering from withdrawal.”
The SPSO also heard that following A’s death the GP surgery had “reviewed their approach to such patients and had recently refused a number of requests to keep on patients living remotely”.
Issuing its ruling, the ombudsman said: “We found that the kinds of medication prescribed to A are implicated in many drug related deaths, often in combination with other substances such as alcohol.
“Taking into consideration A’s history, their mental health, alcohol misuse and history of multiple drug overdoses, early prescriptions should not have been given to A and instalment dispensing should have been used to reduce risk.
“We also found that the evidence did not suggest that A remaining as a patient with the practice had kept them safe, and had influenced the decision not to provide weekly dispending. While it was not possible to say whether this decision had contributed to A’s death, overall, the practice had not provided A with reasonable care and treatment with regard to their prescription medication and on this basis, we upheld B’s complaint.”
Following the ruling, the SPSO ordered the practice to apologise to B “for the failings identified in A’s care and treatment with respect to the prescription medication issued to A.”