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A Yorkshire GP surgery failed to spot the signs of addiction and “drug seeking behaviour” in a young man who was prescribed “a significant number” of pain medicines and went on to have a fatal overdose, a coroner has found. 

Samuel Brown of Rotherham was found dead on March 30 this year as a result of drug intoxication “and a number of those drugs were ones which were prescribed by the GP,” found South Yorkshire East coroner Abigail Combes following an inquiry into the 29-year-old’s death. 

He had registered with a new GP surgery around six weeks before his death, said Ms Combes.  

The practice acknowledged at the inquiry that Samuel should have had a medication review as he “was in receipt of a significant number of medications for pain which he may no longer require,” the coroner found. 

She added: “The previous GPs appear to have continued to add medications to Samuel’s primary care prescription list and he was therefore able to routinely access medications to which he was addicted. 

“Samuel’s family are concerned that his medication was not adequately monitored by general practice and his drug seeking behaviour, linked to his addiction, was not appropriately managed by primary care.”

She wrote to South Yorkshire Integrated Care Board: “As the commissioners for primary care services I am concerned that the prescribing regime in primary care did not identify potential addiction and drug seeking behaviour or review medications with a view to checking they are actually required.” 

The ICB was told it must respond to the coroner’s report by January 22, 2026. 

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