Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0121, written 3 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Mar 2026 |
|---|---|
| Reference | 2026-0121 |
| Deceased | Wendy Boddington |
| Coroner | Peter Nieto |
| Coroner area | Derby and Derbyshire |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: NHS Derby and Derbyshire Integrated Care Board First Floor The Council House Corporation St. Derby DE1 2FS 1 CORONER I am Peter Nieto, senior coroner for the coroner area of Derby and Derbyshire 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 25 March 2025 I commenced an investigation into the death of Wendy BODDINGTON aged 56 (known as Wendy). The investigation concluded at the end of the inquest on 02 March 2026. The conclusion of the inquest was: - Wendy died due to the toxic effects of taking a higher than prescribed fentanyl dose. Prescribed codeine added to the toxicity. 4 CIRCUMSTANCES OF THE DEATH Wendy was found deceased at home by friends who went to check on her on 24 March 2025 after she had not responded to texts and phone calls for several days. Wendy had two fentanyl patches on her body rather than the single patch prescribed. Post-mortem examination with toxicology established that she had a high level of fentanyl in her system recognised to be in the fatal range and codeine would have added to that toxicity. Wendy had been prescribed those medications for chronic pain since 2011, following an accident and amputation of her arm. The court heard that there is now awareness of the risks of long-term prescription of opiates and opioids and fentanyl in particular, concerning complications including tolerance and dependence, with guidance issued to medical practitioners over time as understanding has increased. The fentanyl was prescribed by a GP at Wendy's GP practice in 2011 because Wendy complained that other pain relief had been ineffective. The dose was increased over a short period. At that time GP awareness of the complications of fentanyl was more limited, but in 2014 and 2015 GPs at the practice had attempted to address Wendy's level of opiate and opioid medication, although Wendy was not in agreement. However, Wendy had at least annual medication reviews, and on the evidence there were no clear plans to address this after 2015 which were missed opportunities over a nine to ten year period. There was also a CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 missed opportunity for the specialist hospital pain clinic to raise the fentanyl prescription with the GP practice in 2021. The court heard that it is often the case that opiate and opioid reduction or stoppage can be difficult, and Wendy had expressed objections. There is no positive evidence that Wendy had placed two fentanyl patches on herself to deliberately harm herself, and it is noted that she had fallen and injured her ankle just days before her death and she was probably experiencing increased pain because of that. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: - The context for my concerns is the well-recognised situation of long-term prescription of opiate and opioid medications, often at high doses, for chronic pain. It is now recognised that such prescribing will usually cause other health problems, including dependence and tolerance, and over time becomes limited in controlling pain. Whilst current guidance is against such prescribing, there are many people who have been taking these medications for a long time for whom stopping or reducing the medications is very challenging. Use of those medications carries risk of accidental or deliberate overdose and death. Wendy’s inquest heard that her GP practice has initiated a targeted programme to identify patients who have been receiving long-term prescription of opiate and opioid medications and engage them in focussed review to agree planned reduction, stoppage, or substitution of those medications. This programme involves 2 senior GPs and 2 pharmacists and so is a significant commitment. The practice is incrementally concentrating on those patients with high-dose prescriptions. Relatedly the practice has introduced a number of measures to try and avoid patients being inappropriately prescribed these medications for chronic pain in the first place. In evidence the GP partner stated that he was unaware of other GP practices in the Derbyshire area undertaking similar programmes. The inquest also heard that there are no specialist services for patients who have developed dependence on opiates and opioids, and that substance misuse services will only work with people with non-prescribed drug issues. The inquest did hear anecdotal evidence that NHS England may be pursuing some relevant initiatives but the details and extent of this was unclear. My specific concern is that there appear to be a significant number of people who are being prescribed opiate and opioid medications for chronic pain, often at high doses and for long periods, but may not be receiving support to reduce, stop, or substitute those medications. It appears to me that the ICB is in a position to consider this problem and potential remedies on a regional basis, and feed into national strategies. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by April 28, 2026. I, the coroner, may extend the period. CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Wendy’s family. Lister House Surgery. University Hospitals of Derby and Burton. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. She/he may send a copy of this report to any person who she/he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 3 March 2026 Peter Nieto Senior coroner Derby and Derbyshire CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Regulation 28 Report to Prevent Future Deaths
Derby and Derbyshire Integrated Care Board Response
Derby and Derbyshire Integrated Care Board (DDICB) would like to extend our sympathies
to the family and friends of Wendy Boddington. Please find below the ICBs response and
future plans regarding the Regulation 28 Report to Prevent Future Deaths.
If there are any areas which you feel you would like more information or to discuss in person,
this will be arranged.
Wendy was found deceased at home by friends who went to check on her on 24 March 2025
after she had not responded to texts and phone calls for several days. Wendy had
fentanyl patches on her body rather than the single patch prescribed.
Post-mortem examination with toxicology established that she had a high level of fentanyl in
her system recognised to be in the fatal range and codeine would have added to that toxicity.
Wendy had been prescribed those medications for chronic pain since 2011, following an
accident and amputation of her arm.
The court heard that there is now awareness of the risks of long-term prescription of opiates
and opioids and fentanyl in particular, concerning complications including tolerance and
dependence, with guidance issued to medical practitioners over time as understanding has
increased.
The fentanyl was prescribed by a GP at Wendy's GP practice in 2011 because Wendy
complained that other pain relief had been ineffective. The dose was increased over a short
period. At that time GP awareness of the complications of fentanyl was more limited, but in
2014 and 2015 GPs at the practice had attempted to address Wendy's level of opiate and
opioid medication, although Wendy was not in agreement. However, Wendy had at least
annual medication reviews, and on the evidence, there were no clear plans to address this
after 2015 which were missed opportunities over a nine to ten year period. There was also a
missed opportunity for the specialist hospital pain clinic to raise the fentanyl prescription
with the GP practice in 2021. The court heard that it is often the case that opiate and opioid
reduction or stoppage can be difficult, and Wendy had expressed objections.
There is no positive evidence that Wendy had placed two fentanyl patches on herself to
deliberately harm herself, and it is noted that she had fallen and injured her ankle just days
before her death and she was probably experiencing increased pain because of that.
Coroner concerns
Context - The well-recognised situation of long-term prescription of opiate and opioid
medications, often at high doses, for chronic pain.
It is now recognised that such prescribing will usually cause other health problems, including
dependence and tolerance, and over time becomes limited in controlling pain. Whilst current
guidance is against such prescribing, there are many people who have been taking these
medications for a long time for whom stopping or reducing the medications is very
challenging.
There are no specialist services for patients who have developed dependence on opiates and
opioids, and that substance misuse services will only work with people with non-prescribed
drug issues. The inquest did hear anecdotal evidence that NHS England may be pursuing
some relevant initiatives but the details and extent of this was unclear.
There appear to be a significant number of people who are being prescribed opiate and opioid
medications for chronic pain, often at high doses and for long periods, but may not be
receiving support to reduce, stop, or substitute those medications. It appears to me that the
ICB is in a position to consider this problem and potential remedies on a regional basis, and
feed into national strategies.
Derby and Derbyshire ICB Response
Derby and Derbyshire ICB acknowledges the concerns raised by the coroner in this report and
continues to make every effort to address these and other issues already identified with the
management of chronic pain within the system. A summary of the work done or on-going
within the ICB to this effect, is described below.
System-wide collaborative opioid harm reduction project
The National Patient Safety Improvement Programmes (SIPs) are an NHSE led commission
delivered by the Patient Safety Collaboratives (PSC). One of the four programmes is the
Medicines Safety Improvement Programme (MedSIP) which aims to reduce severe avoidable
medication-related harm by focusing on high-risk drugs and avoidable situations, and
vulnerable patients. One of the priority areas of the MedSIP is improving the management of
chronic non-cancer pain by reducing harm from opioids.
Between January 2022 and March 2025, as part of the national MedSIP, Joined Up Care
Derbyshire (JUCD) Integrated Care System took a systems approach to change opioid
prescribing in chronic non-cancer pain, supported by Health Innovation East Midlands, who
host the East Midlands PSC. The programme involved:
Developing resources for patients and prescribers including
•
Quality Improvement (QI) toolkit with suggested best practice interventions for
Practices who wish to do some focused work on opioid prescribing,
• Minimum standards for opioids repeat prescribing, supporting implementation of
robust procedures specific to their system and patient population while still
maintaining expected safety & quality prescribing standards.
• Opioid tapering resource with a clear focus on reducing opioids.
Education –
• pain management webinars delivered by a national Pain Management Specialist for
local HCPs
• > 80 people trained to practitioner level in the ten footsteps approach to living with
chronic pain.
• Targeted Practice support for Quality Improvement projects
• Optional ICB funded protected Learning (QUEST) sessions for GP practices
Innovation
• Collaboration with the national charity Live Well With Pain to develop and evaluate
digital tools for primary care to support patients and clinicians to perform a holistic
pain management review.
• Roll out of pain support programmes developed in Derby using the evidence based 10
footsteps approach, with 20 pain management support groups facilitated by social
prescribing / health coaching teams set up.
GP Quality schedule
The GP Quality schedule forms part of the wider GP Local Enhanced Services contract under
which practices receive payment from the ICB for meeting the stated quality requirements
over the year. The quality schedule includes several prescribing indicators which are updated
annually.
During the 2025/26 financial year practices were required under the quality schedule, to
identify, produce a register, and complete a review of all non-palliative patients on high dose
opioids (
documentation in the patient record of risks, opportunities for alternative pain management
strategies, exploration of dose reduction/weaning, interacting medication, and ensuring
visible reminders are in place on the patient record to prevent further dose escalation.
oral Morphine equivalent {OME} daily), to include discussion and
Getting it Right First Time (GIRFT) chronic pain review
In January 2026, the ICB participated in an NHS England GIRFT chronic pain virtual system
review, working in collaboration with the Faculty of Pain Medicine and the British Pain Society.
The review looked to identify variation and challenges across the whole chronic pain pathway
to help address challenges in service delivery for pain management, in line with the strategic
aims of the Department of Health and Social Care and NHS England. The aim is to develop a
structured model to ensure patients receive personalised, holistic and evidence-based care
at each stage, with seamless transitions between services– in turn, improving the patient
experience. This is part of a programme of multiple ICS reviews, at the end of which a joint
report will be published, highlighting priority areas for national improvement
The ICB awaits the final report from the GIRFT review and remains committed to
implementing the recommendations in line with national and organisational objectives.
Outcomes to date.
NHS England medicines safety team estimates that for every 62 people who stop (or do not
start) taking opioids, 1 life is saved. Through the actions of this programme and the reduction
in the number of patients receiving long term opioids at least 15 lives have been saved to
date.
Latest available data also shows a decrease in prescribing of high dose opioid items from the
2022 baseline, taking the ICB from the 54th to 44th percentile across ICBs in England.
https://openprescribing.net/measure/opioidspercent/sicbl/15M/
Further planned actions to address concerns
Considering the concerns raised by the coroner in this report, the ICB is undertaking the
following further actions:
Action
The quality schedule will be updated for
2026/27 to again include high dose opioid
reviews, to align with updated
recommendations from the Faculty of Pain
Medicine which now defines high dose
opioid as > 90mg (OME) daily.
ICB funded education sessions for local
prescribing leads focussing on opioid
prescribing.
ICB review and re-procurement of pain
management services
Timescale
Ongoing- expected completion April 2026
May 2026
Ongoing
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