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

Researchers at King’s College London have analysed coroners’ reports from across England, Wales and Northern Ireland to identify safety concerns linked to deaths involving fentanyl patches.

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 Healthcare 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 researchers 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%).

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.

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 healthcare professionals in monitoring safety concerns and improving prescribing practices.

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Source: Kings College London, 18 March 2026