Br J Clin Pharmacol. 2026 Mar 17. doi: 10.1002/bcp.70525. Online ahead of print.
ABSTRACT
AIM: To identify safety concerns reported by coroners following fentanyl patch-related deaths in England, Wales and Northern Ireland, and determine differences in coronial reporting.
METHODS: A systematic case series linking the National Programme on Substance Use Mortality (NPSUM) and the Preventable Deaths Tracker (PDT) (https://preventabledeathstracker.net/) to identify fentanyl patch-related deaths. Keyword searches for ‘patches’ were conducted, and reports were screened for eligibility in duplicate. Data were extracted and descriptively analysed, and deaths were categorized by safety events.
RESULTS: There were 99 fentanyl patch-related deaths between 1997 and 2024, with 89 reported to NPSUM and 12 Prevention of Future Deaths reports (PFDs) from the PDT, with only two duplicates across both databases. Seventy-seven safety events were reported by coroners, with adherence and usage (34%), administration (32%) and prescribing (6%) being the most common. Compared with deaths reported to NPSUM, PFDs were more common for females (58% vs. 33%), older adults (median age: 53 vs. 45 years), occurred more in hospital (42% vs. 9%), were of accidental manner (83% vs. 22%), and were prescribed patches (100% vs. 54%). A live dashboard of PFDs was developed to continue surveillance https://preventabledeathstracker.net/case-study/fentanyl-patches/).
CONCLUSIONS: Safety events, including poor adherence, usage and administration errors of fentanyl patches, were repeatedly identified by coroners, which mostly occurred in males aged 35-49 years. Information from coroners should be systematically monitored to inform the safety of prescribing and use of fentanyl patches, including identifying gaps in care, education and policies.
PROTOCOL REGISTRATION: https://doi.org/10.17605/OSF.IO/GMHNW.
PMID:41844190 | DOI:10.1002/bcp.70525
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