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A coroner has expressed concern over the recording and administration of medication when patients return to care homes, after a patient was given a combination of old and new opioid medication “due to uncertainty in the care home as to which applied, as his discharge letter could not be located”.
In a ‘Prevention of future deaths’ report (PFD), issued to Care UK — a company providing care homes across the UK — on 14 October 2025, David Place, coroner for the City of Sunderland, also raised concerns about the hospital discharge process for patients in care homes, after patient Thompson Elliot died from flu that he contracted in hospital, following treatment for an opioid overdose.
According to the PFD report, Elliot, aged 83 years, was given both his new and previously prescribed medication as his hospital discharge letter could not be located.
He had been admitted to Sunderland Royal Hospital on 12 December 2024 and discharged on 18 December 2024. During his hospital stay, the patient’s medication had been changed from oramorph to oxycodone, owing to the impact that oramorph was having on the patient’s kidneys, the report said.
The coroner wrote that oramorph continued to be administered to the patient on 18–19 December 2024, “before it could be clarified with either the hospital or GP which was the correct medication”.
“The new medication was not administered on either of those days,” he said.
The coroner also said that evidence had revealed that the new medication was not “immediately recorded onto the patient’s electronic medication record and held in a cupboard pending clarification”.
“Despite no clarification and following a 24-hour delay, it was then incorrectly added to the record as new and additional medication — not replacement medication.”
“Due to the administration error in recording oxycodone as new and, therefore, additional medication, the patient was then given both oramorph and the new oxycodone medication on the morning and afternoon of 20 December 2024, which was two days following his discharge. This resulted in an opioid overdose,” the coroner wrote.
“I am concerned that the evidence was such that it was not possible to determine exactly what efforts, if any, were made by staff to clarify the medication position with the hospital on either 18, 19 or 20 December 2024 but medication continued to be administered,” he added.
The patient was readmitted to hospital and successfully treated for the overdose but died on 24 January 2025 from respiratory failure as a result of contracting flu.
“I am concerned that the evidence revealed that there was no policy or guidance document setting out the procedures, which staff must follow in such circumstances, which created confusion and inconsistent decision-making, resulting in a medication overdose and continued use of a medication that had been stopped in hospital due to the harm it was causing to the patient’s kidneys,” the coroner said.
“The evidence raises a further concern that the procedure still remains unclear despite internal reviews following the death.”
Commenting on the coroner’s letter, Samantha Rogan, regional director for the North East at Care UK, said: “Care UK prioritises kind and considerate person-centred care for all residents.
“This was a tragic incident, and we would, once again, like to express our deepest condolences to Mr Elliott’s loved ones. We will be working with our local NHS partners to prioritise clearer communication around medication and hospital discharge. We have also made changes to our medication processes and implemented further training to ensure a similar incident is not repeated in the future.
“We will continue to address the points raised and are in the process of responding to the report from HM coroner.”
The coroner’s letter was copied to South Tyneside and Sunderland NHS Foundation Trust for information, and Care UK have a duty to respond to the coroner within 56 days of the letter being sent.
