In brief: A Jersey inquest has concluded that Michael Connor, 33, died on 20 February last year after overdosing on prescribed opiates and benzodiazepines, despite a clinical nurse warning that he should not receive addictive medication. The acting coroner found that his GP failed to provide a clear clinical explanation for re-prescribing the drugs, and called on Health and Care Jersey to improve information sharing between GPs, prison healthcare teams and psychiatrists.
A life cut short in St Brelade
Michael Connor was found dead by his mother, Carolyn, at his flat in St Brelade on 20 February last year. He was 33 years old and described by family and friends as “well loved”. A two-day inquest, which concluded this week, heard that Mr Connor had struggled throughout his adult life with crippling anxiety and undiagnosed autism, relying on alcohol and drugs to cope. He had also been prescribed pain medication, including powerful opiates and benzodiazepines, for ongoing neck and knee pain.
A post-mortem examination conducted by Dr Niki Stefanos, a consultant histopathologist at the General Hospital, found that Mr Connor had taken a dosage of the benzodiazepine alprazolam, also known as Xanax, in the “fatal range” before his death. He had also taken the opiate dihydrocodeine alongside the alprazolam, which, Bailiwick Express reports, worked in combination with the Xanax to cause the cardiorespiratory depression that led to his death.
A pattern of warnings ignored
The inquest focused heavily on the prescribing decisions made by Dr Geoffrey Hamilton, who had been Mr Connor’s GP since 2015. The sequence of events painted by the hearing is a troubling one.
In May 2024, Mr Connor overdosed on a mixture of his prescription medication and alcohol and was admitted to Orchard Ward for rehabilitation. On discharge, Dr Hamilton was told to avoid prescribing addictive medication “unless the benefit outweighs the risk”. Despite this, on 27 May, and without notifying Mr Connor’s mental health home treatment team, Dr Hamilton recommenced prescribing him opiates and benzodiazepines. Four days later, Mr Connor was rushed to the Emergency Department after a second overdose.
Following that second incident, Dr Hamilton’s colleague Dr Leonard Mirvis intervened and reduced the supply of addictive medication to seven-day amounts. Deputy viscount and acting coroner Matt Berry observed that Mr Connor “did not overdose” for the next three months while those more limited prescriptions were in place.
Mr Connor then served a prison sentence between 9 August and 13 December 2024, during which he underwent a detox from benzodiazepines, opiates and alcohol. Faith Murray, a clinical nurse specialist for the Criminal Justice Pathway, reviewed his mental health on several occasions during his time in custody. At a handover meeting on 3 December, it was agreed that Prison Health Care staff would log an entry on the patient record system warning the GP against prescribing addictive medications. The inquest heard, however, that “it did not appear that such an entry was made”, and that even if it had been, Dr Hamilton did not necessarily have access to the relevant part of the patient record.
Immediately after leaving prison, Mr Connor was re-prescribed a month’s worth of opiates and benzodiazepines by Dr Hamilton. The acting coroner noted that the combination was “very similar to the combination and volume of drugs that, when taking them together with alcohol, Michael had overdosed on twice in May 2024”. Mr Berry concluded that Dr Hamilton had failed to give a “clear, clinical explanation” during his evidence for re-prescribing the medication.
Calls for better information sharing
In his narrative conclusion, Mr Berry intimated that the services put in place for Mr Connor’s release from prison were undermined by his GP. He described Mr Connor’s death as “another timely reminder” of the importance of Health and Care Jersey improving information sharing between GPs, prison healthcare teams and psychiatrists.
The acting coroner suggested that a single patient record “might have assisted professionals with obtaining a better overall understanding” of the medication prescribed to Mr Connor before his death. He was careful to add, however, that “even were such an overview available, it is not apparent to me that it would have affected the approach that Dr Hamilton took to prescribing in this case.” Mr Berry concluded the inquest by offering his condolences to Mr Connor’s family.
Source: Bailiwick Express
