I am a pharmacist with an MSc in Advanced Pharmacology and am currently a PhD candidate in the Centre for Pharmaceutical Medicine Research at King’s College London. My research focuses on the impact of psychoactive substances, including cannabis and novel products like non-alcoholic drinks, on drug driving. I also examine UK drug-driving legislation and its implications for public health and policy. I am passionate about promoting evidence-based strategies to enhance drug safety and reduce drug-related harm.

Abstract

Safety concerns of fentanyl patch fatalities reported by coroners in England, Wales, and Northern Ireland

Fentanyl deaths have increased in the UK from 1 case in 1999 to 57 cases in 2022. Research outside the UK has found that fentanyl patches have contributed to overdoses and misuse. However, no systematic assessment of fentanyl-patch-related deaths in the UK has been conducted. This study aims to identify safety issues reported by coroners following fentanyl patch fatalities by linking data from coroners’ reports. A systematic retrospective case series was designed and registered on an open repository. Data from the National Programme on Substance Use Mortality (NPSUM) and the Preventable Deaths Tracker (PDT) were searched to identify coroner reports involving fentanyl patches. Each included case was categorised by the safety event reported by the coroner and the procurement of the patches. Descriptive analyses were conducted using SPSS and Google Sheets. There were 98 fentanyl-patch related cases identified in NPSUM and PDT between 1997 and August 2024. The most common safety events reported by coroners in fentanyl-patch related deaths were route of administration (34%), which includes oral, inhalation, and injection of the fentanyl patch. Multiple wearing of fentanyl patches on the body was commonly reported (33%). This is the first study to combine data from multiple sources involving deaths following the use of fentanyl patches in England, Wales, and Northern Ireland. It highlights the need for enhanced pharmacovigilance for the prescribing of fentanyl patches and the importance of using coroners data to inform the safe use of medicines.