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Coroner warns about poor drug reviews after patient dies from tramadol overdose

BMJ 2020; 370 doi: (Published 05 August 2020) Cite this as: BMJ 2020;370:m3101
  1. Clare Dyer
  1. The BMJ

A senior coroner has demanded action by Simon Stevens, chief executive of NHS England, to ensure that GPs monitor repeat prescriptions properly, after an 84 year old man with dementia died from an overdose of tramadol.

Peter Cole, who was found collapsed at his home in Welwyn in Hertfordshire by a neighbour, had amassed a large quantity of unused prescription drugs at his house. He had numerous drugs on repeat prescription, said Geoffrey Sullivan, chief coroner for Hertfordshire. One was the opiate painkiller tramadol, for which he had had a repeat …

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