Study of coroners’ reports highlights safety concerns linked to fentanyl patch deaths

Fentanyl is a highly potent and fast-acting synthetic opioid used to treat severe pain and is available in several forms, including injections, nasal sprays and skin patches. The study, which is published in the British Journal of Clinical Pharmacology, examined deaths associated with transdermal fentanyl patches between 1997 and 2024.

While fentanyl can be an effective treatment for pain, it has also been linked to increasing numbers of drug-related deaths worldwide. In the UK, the Medicines and Health care products Regulatory Agency (MHRA) has issued several safety warnings about the risk of accidental exposure to fentanyl patches and the importance of safe disposal.

To better understand the risks, the research, led by Eman Mshari, Dr. Caroline Copeland and Dr. Georgia Richards, conducted a systematic case series linking two national sources of coronial data, the National Programme on Substance Use Mortality (NPSUM), and the Preventable Deaths Tracker, which collects coroners’ Prevention of Future Deaths (PFD) reports. By linking these datasets, the team created the first comprehensive overview of fentanyl patch-related deaths reported by coroners.

The analysis identified 99 deaths involving fentanyl patches between 1997 and 2024. Coroners reported 77 safety events linked to these deaths, with the most common issues relating to adherence and usage (34%), administration errors (32%) and prescribing practices (6%).

Most deaths occurred in men aged between 35 and 49 years, although Prevention of Future Deaths reports were more commonly issued for women, older adults and hospital settings. Many of these cases involved accidental deaths and situations where fentanyl patches had been prescribed as part of medical treatment.

The study also highlights differences in how deaths are reported across the two datasets, suggesting that important safety information from coroners may not always be systematically captured or monitored.

“Our research demonstrates that health care professionals should remain vigilant when prescribing and dispensing fentanyl patches due to their risk of accidental deaths and potential misuse. Improved patient care and prescribing practices could also help reduce drug-related harm,” said first author Eman Mshari, a Ph.D. student at King’s.

Suggested measures from the research include introducing dual review systems for fentanyl patch prescriptions, providing clearer medication guidance for patients, and ensuring regular medication reviews. In some cases, alternative non-opioid treatments for chronic pain may also need to be considered.

As part of the project, the team also developed a live online dashboard that tracks Prevention of Future Deaths reports involving fentanyl patches in real time. The researchers hope this tool will support regulators, policymakers and health care professionals in monitoring safety concerns and improving prescribing practices.

“This is the first study to bring together two unique data sources from coroners, which are currently being underutilized by the government, public bodies, regulators and researchers. Our study demonstrates the value of this data linkage, and the need for sustainable data infrastructure to continue building tools that foster patient and public safety,” said Dr. Georgia Richards, AI+ Academic Senior Fellow and epidemiologist at King’s.