A Jerseyman described as “well loved” by his family and friends died after overdosing on drugs supplied to him by his GP – despite a clinical nurse warning that he should not be prescribed addictive medication.
On 20 February last year, Michael Connor was found by his mother, Carolyn, lying dead at his flat in St Brelade at the age of just 33.
A two-day inquest into his death, which concluded yesterday, focused heavily on the decisions made to prescribe the Islander “powerful” psychoactive medication after his discharge from a four-month prison sentence in December 2024.
GP warned not to prescribe addictive medication “unless benefit outweighs the risk”
The hearing was told that Mr Connor relied on alcohol and drugs throughout his adult life to help cope with crippling anxiety and undiagnosed autism.
It was heard that he was also prescribed pain medication – comprising both powerful opiates and benzodiazepines – to help him cope with ongoing neck and knee pain.
On 5 May 2024, he overdosed on a mixture of his prescription medication and alcohol – and was admitted to Orchard Ward for rehabilitation.
The inquest was told that after being discharged from Orchard Ward, his GP, Dr Geoffrey Hamilton, was told to avoid prescribing Mr Connor addictive medication “unless the benefit outweighs the risk”.
However, 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, the inquest heard, Mr Connor was rushed to the Emergency Department after overdosing on alcohol and the drugs prescribed to him by his GP.
Following the second overdose, Dr Hamilton’s colleague, Dr Leonard Mirvis, intervened and reduced Mr Connor’s supply of addictive medication to seven days at a time.
Deputy viscount and acting coroner Matt Berry observed that the Jerseyman “did not overdose” for the next three months “while more limited prescriptions were given”.
No “clear, clinical” explanation for prescribing
Mr Connor served a short prison sentence between 9 August 2024 and 13 December 2024, during which he commenced a detox from benzodiazepines, opiates and alcohol.
Faith Murray, a clinical nurse specialist for the Criminal Justice Pathway, told the inquest that she reviewed Mr Connor’s mental health on several occasions during his time in custody.
It was heard that, during a handover meeting on 3 December, it was agreed that the Prison Health Care staff would log an entry on the patient record system to inform the GP that he should avoid prescribing addictive medications to Mr Connor.
But, the hearing was told that “it did not appear that such an entry was made”, and that – even if it was – the GP 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 of drugs prescribed by Dr Hamilton 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”.
He concluded that Dr Hamilton, who had been Mr Connor’s GP since 2015, had failed to give a “clear, clinical explanation” during his evidence for re-prescribing the medication.
Case a “timely reminder” of the need to improve information sharing
A post-mortem examination conducted by Dr Niki Stefanos, a consultant histopathologist at the General Hospital, was read into the record as part of the proceedings.
Giving evidence, she said that Mr Connor was found to have taken a dosage of a benzodiazepine called alprazolam – also known as Xanax – in the “fatal range” before his death on 20 February.
Dr Stefanos reported that he had also taken the opiate dihydrocodeine alongside the alprazolam, which worked alongside the Xanax to help cause the cardiorespiratory depression that led to Mr Connor’s death.
In Mr Berry’s narrative conclusion, the acting coroner intimated that the services “put in place” for Mr Connor’s release from prison were undermined by his GP.
He also said that Mr Connor’s death is “another timely reminder” of the importance of Health and Care Jersey improving information sharing between GPs, prison healthcare teams and psychiatrists.
He 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.
“However, he concluded, “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 the family of Mr Connor.
