Coroner's concern over woman's fentanyl death

A coroner has raised concerns over people being prescribed opioid medications at high dosages without support, after a woman died from a fentanyl overdose.

Wendy Boddington was found dead at home on 24 March 2025, with two fentanyl patches on her body, rather than the single patch she was prescribed for chronic pain, an inquest heard.

Following the inquest conclusion this March, senior coroner for Derby and Derbyshire Peter Nieto called for local NHS bosses to take action to prevent future deaths.

The NHS Integrated Care Board (ICB) said it would consider the findings of the report and "reflect on any lessons identified".

Fentanyl and codeine are strong pain medications which can be addictive.

Boddington had been prescribed the pain management medications since 2011, following an accident and amputation of her arm.

The inquest into her death heard her friends discovered her dead at home after she had not responded to texts or phone calls for several days.

Nieto concluded the woman died "due to the toxic effects of taking a higher than prescribed fentanyl dose", while prescribed codeine "added to the toxicity".

The coroner said there was no positive evidence that the 56-year-old used the two patches to deliberately harm herself.

It was also noted that days before her death, she had fallen and injured her ankle, and was "probably experiencing increased pain because of that".

The inquest heard the fentanyl was prescribed because she had complained other pain relief had been ineffective, and that the dose was increased over a short period.

A prevention of future deaths report said, GP awareness of the complications of fentanyl was more limited at the time.

Boddington's GPs had attempted to address the level of opiate and opioid medication with her in 2014 and 2015.

However, the court heard she was not in agreement with the discussions.

The coroner said Boddington still had annual medication reviews but evidence showed after 2015, there were "missed opportunities" to address her medication over a nine to 10 year period.

There was also a missed opportunity for a specialist hospital pain clinic to raise the matter of the fentanyl prescription with Boddington's GP practice in 2021, the coroner said.

The court heard opiate and opioid reduction and stoppage could be difficult, and that Boddington "had expressed objections".

In a prevention of future deaths report - sent when a coroner thinks action is needed to protect lives - Nieto said: "My specific concern is that there appear to be a significant number of people who are being prescribed opiate and opioid medications for chronic pain, often at high doses and for long periods, but may not be receiving support to reduce, stop, or substitute those medications."

The inquest heard Boddington's GP practice had started a programme to identify patients receiving long-term prescriptions for such medication, and to help them with agreed planned reduction, stoppage or substitution of them.

The practice had also introduced measures in an attempt to avoid patients being inappropriately prescribed opiate and opioid medications for chronic pain.

In his evidence, a GP partner said he was unaware of other practices in the Derbyshire area carrying out similar programmes, according to the report.

He also told the inquest there were "no specialist services" for patients who had developed a dependency on opiates and opioids, and that substance misuse services only worked with those with "non-prescribed drug issues".

A spokesperson for the NHS Derby and Derbyshire ICB said: "We extend our sincere sympathies to the family and friends of Wendy Boddington following their tragic loss.

"We will consider the findings of the prevention of future deaths report carefully and reflect on any lessons identified."

The ICB will have until 28 April to respond to the coroner's report.

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