On Tuesday 1Oth September 2019 Russell Caller , Assistant Coronerheard the inquest of Michael Lobban who was found dead at his home on Monday 23rd October 2017 Medical Cause of Death (a) Mixed Consumption when and where and in what circumstances the deceased came by his death: Michael Lobban was on a prescription of Smg Methadone tablets and was required to pick up his prescription form Boots, Queensway London Branch on & regular basis_ Michael Lobban was known to the staff at this Boots branch: On Thursday 1gh October 2017 Michael Lobban picked up 68 x Smg Methadone tablets in accordance with his prescription_The following_Thursday 26th October 2017 during_a Controlled Drug_ Thane Drugs Drug How;

Running Balance audit check by Boots, Queensway Branch there was a disparity in the numbers of Methadone tablets. It transpires there were 51x Smg methadone tablets missing: On the Monday prior to this audit check on Monday 23rd October 2017 days before Boots discovered the disparity of 51 of methadone tablets) Michael Lobban was found dead in his home at 31c Talbot Road London W2 5JG with; inter alia, an excessive amount of methadone in his blood 0.56 uglml in his blood) which amounts to significant overdose of methadone. There were other drugs found in Michael Lobban's in the toxicology report taken after death. Conclusion as to the death: Related

For many years Michael Lobban had been suffering from serious mental health issues and had been under the and Alcohol Well-being Service (DAWS) for a number of years . He suffered from dependency and mental illness and had periods of overdosing causing self-harm and there had been threats of suicide_ Michael Lobban was on a prescription of Smg Methadone tablets and was required to pick up his prescription form Boots, Queensway London Branch on a basis. Michael Lobban was known to the staff at this Boots branch: On Thursday 1gih October 2017 Michael Lobban picked up 68 X Methadone tablets in accordance with his prescription: On the following Thursday 26h October 2017 a Controlled Drug Running Balance audit check by Boots, Queensway Branch there was a disparity in the numbers of Methadone tablets. It transpires there were 51x Smg methadone tablets missing: On the Monday prior to the audit check on Monday 23rd October 2017 3 days before Boots discovered the disparity of 51 x 5 mg of methadone tablets) Michael Lobban was found dead in his home with, inter alia, an excessive amount of methadone in his blood 0.56 ug/ml in his blood) which amounts to a significant overdose of methadone There were other drugs found in Michael Lobban's body in the toxicology report taken after death.

In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation have the power to take such action. It is for each addressee to respond t0 matters relevant to them. The Council should implement industry wide policies and reporting requirements by pharmaceutical companies in relation to Drug Discrepancy for all Controlled drugs and
2.The Boots Company PLC should review its processes and procedures in dealing with occurrences f drug disparity for controlled drugs which should include: A): make robust rules to ensure contact with a patient or third party that could be affected by a disparity of controlled drugs_ B) ensure the physical checking of the contents of prescription boxes for controlled drugs is robust and secure C) to implement a second check in relation to the controlled drug register for Controlled drugs_