Steven Fone
PFD Report
Historic (No Identified Response)
Ref: 2017-0101
No published response · Over 2 years old
Sent To
Response Status
Responses
0 of 1
56-Day Deadline
11 Jul 2017
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
In the circumstances it is my statutory duty to report (o you. _ During the course of evidence at the Inquest was informed that Adams Pharmacy permitted three separate customers in receipt of prescriptions to interchangeably collect each other's prescriptions_ No documentation was before the court to confirm whether consent had been given by any customer: would like to know whether this practice is approved of by the relevant regulator of pharmacies. It seems to me this practice could be open t0 abuse and facilitate stock-piling leading to an increased risk of harm or death to those prescribed medicines which have the propensity to be fatal if taken outside the recommended guidance_
Action Should Be Taken
In my opinion action should be taken t0 prevent future deaths and believe you have the power to take such action.
Report Sections
Investigation and Inquest
On 4"h November 2016 commenced an investigation into the death of Steven Thomas Fone. The investigation concluded on the 23" March 201 and the conclusion was one of misadventure. The medical cause of death was 1a) Combined toxic effects of tramadol, cocaine, amitriptyline, methadone, pregabalin and heroin:
Circumstances of the Death
Steven Fone died on 31st October 2016 at Ashton under Lyne following the consumption of a fatal cocktail of tramadol, cocaine, amitriptyline; methadone, pregabalin and heroin:
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.