Coroner criticises Dunstable GP surgery over woman’s opioid death

A GP surgery in Dunstable has been criticised by a coroner over the death of a 59-year-old woman who had been prescribed opioid drugs for around 14 years.

Joy Ebanks died from oxycodone toxicity in May 2023. Dr Sean Cummings, assistant coroner for Bedfordshire and Luton, said there was "no evidence" to suggest a plan was created by her GP practice, Kirby Road Surgery, to reduce her dosages.

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

The report said there was "a risk that future deaths could occur unless action is taken". But the surgery says it will put an action plan together.

A spokesperson for Kirby Road Surgery said: “We were saddened by the death of Mrs Ebanks and again express our condolences to her family, friends and loved ones.

“We have received a copy of the Coroner’s report. We are currently considering the contents of his report, and will reply with an action plan to address the matters raised.”

The report by Dr Cummings stated Mrs Ebanks had been prescribed opiates “since at least 2009". It added she had been self neglecting and not engaging with support services, and that she suffered from Fibromyalgia, arthritis, agoraphobia and had been diagnosed with depression.