Peter Nieto, senior coroner for the coroner area of Derby and Derbyshire, found Margaret Feeney, who was found deceased at her home address on 1 April 2024, had died following an overdose of medication due to medical prescribing decisions and arrangements leading up to a bank holiday period.

Feeney had been limited to seven-day prescriptions due to her long use and dependence on benzodiazepines and codeine. However, she was given excess prescriptions of the drug after she received a new lower dosage from her GP on top of her regular dosage as well as an early prescription to cover the bank holiday period.

In his prevention of future deaths report, the coroner expressed concerns that measures were not in place at Macklin Street Surgery and Daynight pharmacy to prevent prescription of excess medication to patients at risk of overdose.

An NHS Derby and Derbyshire Integrated Care Board spokesperson said: ‘We extend our sympathies to the family and friends of Margaret Feeney over their loss.

‘NHS Derby and Derbyshire works with GP practices and community pharmacies to ensure good prescribing practice in all healthcare settings and we will consider the report's findings carefully.'

Macklin Street Surgery and Daynight Pharmacy declined to comment when contacted by HM.