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Medicines prescribed on repeat prescriptions — particularly opioids — can contribute to patient harm and medicine-related deaths, a study has found.
The study, published on 21 April 2025 in Springer Nature, analysed coroners’ prevention of future deaths (PFD) reports on medication-related deaths in England published between January 2019 and December 2023. It found that a failure to review medicines in primary care is an important factor in harm and deaths.
The results showed that 24 out of 4,781 PFD reports related to medication repeat prescribing.
Opioid analgesics made up 76% of the medications named in the PFD reports, which prompted the researchers to call for an urgent review of the drugs.
In addition, the researchers found that most (67%) of the reported deaths were in female patients, with a median age of 44.5 years.
The analysis also stated that coroners attributed deaths to a cumulation of multiple actions, medications and/or conditions.
Of the 47 causes of death included in the final patient sample, single-drug toxicity and multiple medications were each referenced 12 times (25.5%), with the remaining 23 deaths being attributed to other medical causes of death, the results showed.
The study also revealed that between January 2019 and December 2023, coroners raised 54 matters of concern, with the absence of medication review among the reasons most frequently linked to patient deaths.
Other major themes observed in the study were errors or discrepancies at the point of a transfer of care and the ability to obtain repeat prescriptions from multiple medication sources.
The authors, who are based at the Royal Pharmaceutical Society (RPS), said: “Our research has highlighted a gap in failure to reply and, potentially, a failure to act, despite this being a statutory requirement.
“Analysis of the responses to the PFD reports, and the action taken by recipients, may offer further insights into preventative actions taken.”
In 2024, the RPS and Royal College of GPs (RCGPs) teamed up to develop the first repeat prescribing toolkit in 20 years, in an attempt to assist primary care teams with streamlining repeat prescribing and cutting medicines waste.
Commenting on the study, Wing Tang, head of professional standards at the RPS, told The Pharmaceutical Journal: “This study reviewed PFD reports issued by coroners over a four-year period, finding that repeat medicines have caused fatalities. The absence of a robust medication review was identified to be the most common theme in these deaths.
“This study informed our work to develop the RPS/RCGP repeat prescribing toolkit, which aims to better protect patients receiving repeat medicines. The study also outlines the impact that structured medication reviews have for patient safety, and we strongly believe that pharmacy teams in primary care should be resourced to prioritise such reviews for high-risk patients.”
According to the NHS Business Services Authority, nearly 1.2 billion prescribed medicines were dispensed in the community in England between 2022 and 2023.
The Department of Health and Social Care was contacted for comment.
