Hamish Hardie died at his home in Harsfold Lane, Billinghurst on August 16, last year, after accidentally overdosing on medication for severe back pain, he received at Loxwood Medical Practice.
An inquest at Crawley Coroner's Court on Thursday (January 23) heard how Mr Hardie, a public relations consultant, was 'on the road to recovery' after a history of drug dependency, but died following an 'unfortunate error'.
Mr Hardie’s mother Mary-Anne, who was in charge of her son’s medication, told the inquest that he was given a prescription of oramorph, dihydrocodeine and diazepam but the dosage was not written on the oramorph bottle.
She said: "I collected the prescription and it said use as directed on the bottle. The prescription was not written on the bottle. It didn't say how much to use.
"It was a mistake that could have been avoided if the proper dosage was on the bottle.
"I checked the prescription label but I relied on Hamish to tell me what the direction was. In retrospect, I should have called the hospital.
"I kept his medication locked away because of his previous issues. He had no access to it. If I went out, I took both keys with me. I was aware of the dangers."
'Lack of experience' behind absence of instructions on prescription
The inquest heard that Mr Hardie was treated by doctor Carlos Novo, who said he was in the third year as a trainee GP, working under the supervision of doctor Emma Woodcock.
Ms Hardie said she was not party to any discussions her son had with Dr Novo, who she met once in the waiting room after finding out he had seen her son instead of Dr Woodcock as planned.
Giving evidence at the inquest, Dr Novo said he didn't know Ms Hardie was in charge of her son's medication, and didn't know if he had consent to speak to her about his dosage.
Dr Novo said he wasn't aware of the patient's drug history because it wasn't clearly marked in his medical notes.
He added: "He was in a lot of discomfort. I tried to understand the pain complaints and I looked for any red flags.
"I had discussions with Dr Woodcock about how we could move the treatment forward and we agreed on what medication to give him."
After being questioned by Karen Henderson, the assistant coroner for West Sussex, Dr Novo admitted that he did 'have the capability' and it was his responsibility to write the full the prescription on the bottle but a 'lack of experience' may have led to him not doing so.
Mrs Henderson told Dr Novo that he had 'a duty of care' to ensure a controlled drug was administered correctly. Dr Novo said since Hamish's death, he has endeavoured to 'develop my understanding'.
Medical practice to make changes
Dr Woodcock, a GP trainer and doctor of 20 years, explained that there was a template system in place, where 'use as directed' or abbreviations including OD, meaning once a day, were used. She revealed that changes to this system have been made with all staff instructed to write the full prescription.
Dr Woodcock said she 'wasn't familiar' with the patient and wasn't aware of his current medical situation prior to discussions with Dr Novo.
She added that the day Hamish was first seen by Doctor Novo was 'particularly busy', and she was trying to 'manage the workload'.
She added: "If it hadn't have been, I may not have asked Carlos to see that patient. If I had known his history, I would have seen him myself.
"The first change [we will make] is that any alert is highlighted on the front cover of the medical notes."
A post mortem examination found that the cause of death was 1A drug overdose after suffering a prolapsed disk.
It said morphine was detected in the blood showing severe toxicity, whilst there were 'extremely consistent' signs of respiratory depression, leading to respiratory arrest.
Mrs Henderson said there was 'no dispute' about the confusion over what doses should have been given but she was unable to reach a conclusion without an opinion of an independent medical expert.
'This needs to be considered nationally'
Following the inquest, which was adjourned, Tim Deeming of Tees law released a statement on behalf of the family.
He said: "The coroner has now heard part of the evidence in relation to the inquest and will be considering further opinions to enable her to reach a conclusion.
"Hamish was a devoted son, brother, uncle and great friend to many and is dearly missed. Hamish graduated from Leeds Uni with a 2:1 in international history and politics and then worked in public affairs and business.
"It is reassuring to hear that further training and systems have been put in place at the GPs' but we remain concerned that this needs to be considered nationally to ensure that such tragic circumstances do not arise again, and that patient safety is enhanced, given that such events could sadly be repeated elsewhere."