A Durham pharmacy’s actions “contributed more than minimally” to the overdose death of a man in June 2023, a coroner has found. 

In a report to prevent future deaths that was published on August 16, coroner Janine Richards said that York Road Pharmacy in Peterlee had supplied Anthony Paul Nixon with “additional methadone on multiple occasions, not in accordance with the prescription for such”. 

Mr Nixon was found dead in his home on June 12, 2023 at the age of 45, with the medical cause of death cited as the “combined toxic effect” of several substances. 

A pharmacist who gave evidence to the coroner’s inquiry reported that he “believed he had a discretion” to provide certain medications “in advance” and not in accordance with the prescription for supervised provision on specific days.

The coroner found that the pharmacist had misinterpreted instructions on the prescription that stated: “Please dispense instalments due on a pharmacy closed days on a prior suitable date.” 

The pharmacist allegedly interpreted this “to include Saturdays when the pharmacy was open for half a day, despite the prescriptions stipulating the specific days” that medication was to be provided. He told the coroner that this was “standard practice” at the pharmacy. 

This “led to a situation where the deceased was in possession of multiple doses of a controlled drug… on a regular basis in the period leading up to his death,” said the coroner, adding that this “was not in accordance with the prescription, which had been carefully considered to attempt to manage the obvious risks of such”. 

The coroner said the pharmacy had been “specifically chosen” by Mr Nixon’s drug treatment provider because it could provide supervised administration “on a six day per week basis” and said she was concerned that the treatment provider had not been alerted that “the deceased was regularly receiving additional doses”. 

She said she was “not reassured” that the pharmacist “fully appreciates the gravity of this situation” and that in his evidence he “continued to maintain that he could exercise a discretion in relation to the provision” of the drug that was prescribed, something he described as “standard practice”. 

The coroner said she had written to the General Pharmaceutical Council but had not received an update on whether an investigation has been launched or whether the pharmacy has been advised to take specific action to prevent similar risks arising in the future. 

The pharmacy and the GPhC are obliged to respond to the report by November 11 outlining any actions they propose to take or an explanation as to why no action is needed. A copy of the report was sent to chief Judge Alexia Durran, chief coroner for England and Wales. 

A GPhC spokesperson said: "We are very sorry to hear about the death of Mr Nixon. We take any Prevention of Future Death reports extremely seriously. We are looking into concerns raised by the coroner and are assessing whether improvements may be needed at York Road Pharmacy in the light of this report."