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All pharmacies in the UK should be providing advice to patients on the proper disposal of used fentanyl opioid patches to avoid incorrect use and misuse, says Terry Maguire…

Christopher McDonagh Marshall died of a fentanyl overdose. It was November 2023 at about 5.30pm at his home in Rosslea, County Tipperary, Ireland.

He had been playing, as he normally did, around the house on that awful afternoon, getting into mischief. The family was planning an early Christmas with his uncle Joe, who was terminally ill. Joe would die in January 2024 aged 24.

His grandmother found Christopher, as she thought, asleep on his bedroom floor across the hall from his uncle Joe’s room. As she lifted him into bed, she noticed his lips were blue and he was not breathing.

Hysterical, she ran into the street seeking help and was helped by a wider family circle who live in close proximity. The emergency services were called and arrived promptly but in spite of first aid and clinical intervention, Christopher was pronounced dead at just after seven in the evening in hospital.

The autopsy revealed fentanyl toxicity, 10 times the adult clinical dose. The accepted narrative at his inquest on July 11, 2025 was that the child had somehow come into contact with the Durogesic 100 mcg/hr TTX patch his uncle Joe used for pain relief.

The coroner identified this as “the first case of its kind in Ireland” and planned to address these tragic consequences with various responsible agencies. He said it was a “totally avoidable death” and “must never happen again”. 

Not the first time

But it has happened before, elsewhere, which means that after those tragedies where a coroner in a different jurisdiction mandated it must never happen again, it has happened again. 

Amelia Grace Cooper, from Newquay, Cornwall, was found lifeless in her parents’ bed on June 5, 2016. Police said there was “every indication” Amelia died after a fentanyl opioid patch became attached to her, but “insufficient evidence” existed as to how this happened.

The inquest at Bodmin Magistrates' Court ended with an “open conclusion” and the cause of death recorded as “fentanyl toxicity”. It is very likely Amelia came into contact with her mother's patch – used for pain relief – while "sharing a bed.

Police said there was “insufficient evidence” of how the patch ended up on Amelia's body.

Police said the cause of death was “the careless actions and neglect of the prescribed mediation”. On the instructions of the coroner, the medicines regulator MHRA issued advice in 2018 on how to reduce the risk of this happening again.

In the US, a grandmother gave her six-year-old grandchild a dose of ibuprofen for a neck strain and found it did not adequately relieve the pain, so she decided to apply her used fentanyl patch to the child’s neck for additional pain relief.

The child died and the grandmother was charged with criminal gross negligence. Sentencing, the judge said it must never happen again.

In another US case, a two-year-old boy died after he placed a fentanyl patch in his mouth after he ran over it with his toy truck on the floor of his great grandmother’s room in a long-term care facility.  

Patient education in the safe use of fentanyl patches is essential due to their unique delivery system and the drug potency which presents significant dangers. Above all, there is a duty of care to patients to ensure they appreciate the drug is extremely dangerous if used incorrectly.

Because it is a patch formulation, it is important that some discussion with the patient or their representative happens at least on first dispensing but this is currently not common practice in most UK and Irish pharmacies.

There must be advice on proper disposal of used patches to avoid incorrect use and misuse.

The loss of a child in such tragic circumstances comes with highly charged emotions. No doubt the family will be looking for answers. If it was, as the coroner claims, a total avoidable death, then they rightly will seek these answers.

What was or was not done by the professionals involved? What steps did they or should they have taken to ensure this outcome was avoided?

It’s mostly unhelpful to only point a finger of blame and much more productive to forensically dissect the sequence of events that led up to the tragedy so future practice will assure, as much as possible, it will never happen again.

In his recommendations, the Irish coroner said he will do his bit and other professions will be involved but community pharmacy needs to provide better advice when this medicine is supplied to ensure there is never again another totally avoidable death.

Terry Maguire is a leading pharmacist in Northern Ireland.