In the circumstances it is my statutory to report to you. heard during the inquest that Mr Earp had been prescribed Fentanyl which was administered by way of transdermal patches_ Mr Earp repeatedly requested additional patches however there was no evidence that all of the "unspent" patches had been returned to the nursing staff or appropriately discarded: The clinical staff believed that Mr Earp was accessing illicit drugs when he left the ward, however there was no evidence that staff considered that he may have been taking additional Fentanyl and illicit medication, and the effect this could have would ask that consideration is given to providing staff with guidance on how to manage the administration and provision of prescribed drugs when the patient is also accessing non-prescribed potentially illicit drugs Gloucestershire Coroner'$ Court; Corinium Avenue Barnwood, Gloucester, GL4 3DJ Tel 01452 305661 Fax 01452 412618 duty