Publisher Health

A coroner has criticised a doctors’ surgery over the death of a woman who had been prescribed opioid drugs for about 14 years.

Joy Ebanks, 59, died from oxycodone toxicity in May last year.

Sean Cummings, the assistant coroner for Bedfordshire and Luton, said there was “no evidence” to suggest a plan was formed by Kirby Road Surgery in Dunstable to reduce the dosages.

The surgery said it would put together an action plan.

In his prevention of future deaths report, Dr Cummings said Mrs Ebanks was taking oxycodone and pregabalin as pain treatment and her primary cause of death was “oxycodone toxicity enhanced by pregabalin intake”.

Oxycodone is an opioid painkiller used to treat severe pain. Long-term use is associated with physical and mental health issues, heart conditions and accidental overdoses.

Mrs Ebanks suffered from fibromyalgia, arthritis, agoraphobia and was diagnosed with depression, Dr Cummings said.

She was prescribed venlafaxine and quetiapine – both used to treat mental health conditions – and took cannabis.

The patient lived alone, had not engaged with support and had “been self-neglecting”, the report added.

She was found unresponsive by her care worker on 24 May 2023 and was pronounced dead at the scene.

Dr Cummings said Mrs Ebanks had been prescribed “opiates since at least 2009”.

Medication reviews were largely done by telephone because of her agoraphobia and dislike of people coming to her home, he wrote.

“There was evidence of poor communications between the agencies providing her with different aspects of her care,” he said.

“There was no evidence of any attempt to review the prescriptions of two dependency forming drugs with a view to reducing the dose over time. The opioid prescription was high.”

The report said there was “a risk that future deaths could occur unless action is taken”.

The surgery said it was saddened by her death and added: “We are currently considering the contents of his report and will reply with an action plan to address the matters raised.”

A copy of the report was also sent to the East London NHS Foundation Trust which “may find it useful or of interest”, Dr Cummings said.

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