Borough healthcare providers have been ordered to review their "red flag" system after a prescription failure led to the death of a Wigan man.
Paul Mullen, 37, was found dead in his Platt Bridge flat on June 22 last year, following a heroin and methadone overdose.
Coroner Alan Walsh, who conducted Mr Mullen’s inquest back in November, has written to the head of Hindley Health Centre Pharmacy and the chief executive of Greater Manchester Mental Health NHS after it was found that no alarms were raised when he did not pick up his methadone prescription for three days.
Mr Walsh ascertained that Mr Mullen, a long-standing heroin and crack cocaine user, had been "very diligent" in collection his prescription "each and every day" until five days before his death.
His Addaction recovery worker, Debbie McGinnis, halted his prescription on the fourth day in a bid to re-establish connection with him when he missed appointment4 hours later, she raised the alarm and contacted his mum, Cathering Grundy, who found him dead in the bathroom.
Bolton assistant coroner Alan Walsh said the red flag’ system was supposed to act as an early warning mechanism if a methadone user had not picked up a prescription for three straight days.
In the "report to prevent future deaths, Mr Walsh outlined his concerns regarding Mr Mullen’s death and review requirements.
He highlighted that the father-of-two did not collect his prescription for three days starting on June 18, but that his key worker was not notified about this until she phoned up personally on day four to ask for a halt on his prescription as he had not been turning up for meetings.
Mr Walsh added: "The key worker also gave evidence that some patients, particularly those patients who are known to be diligent and to collect their medication on time each and every day, may require a report of non-collection of medication earlier than three days because, in relation to those patients, a single failure to collect medication may cause concerns and require inquiries by the key worker…"
Concerns were also raised that a report made to GMMH was not forwarded on to the key worker at Addaction.
The coroner has requested that the services consider reporting directly to the key worker to avoid it being processed by someone unrelated to the case.
He said: "The review should consider the most expeditious route to report the failure to collect prescribed medications to a Key Worker, who has the responsibility in relation to the patient and who will have direct contact with the patient.
"The Key Worker will be the most expedient method of contact with the patient."
He also ordered them to consider variations to the three-day timescale when a patient fails to pick up their prescription, saying that this may not be "appropriate" for all patients.
Training has also been requested for all pharmacy, mental health practitioners and any other healthcare professionals regarding the reporting of people failing to collect their prescriptions.
He said: "In my opinion urgent action should be taken to prevent future deaths and I believe that you have the power to take such action."
Both providers were told to respond to the coroner with details of proposed actions.