Terry Maguire stresses the urgent need for patient education on the safe use of fentanyl patches to avoid future tragedies
Christopher McDonagh-Marshall died of a fentanyl overdose. It was November 2023 at about 5.30pm in his home in Rosslea, Co Tipperary. Christopher was not a drug user — he was a 20-month-old child. And his supply of fentanyl was not from a street dealer, but from a fully regulated source: A community pharmacy.
Christopher lived with his mother, grandmother, uncle, and aunt in his grandmother’s four-bedroom home. He had been playing, as he normally did, around the house that afternoon, getting into mischief. The family was planning an early Christmas as his uncle Joe, who was terminally ill, might not live. Joe eventually passed away in January 2024 aged 24.
His grandmother found Christopher on his bedroom floor, which was across the hall from his uncle Joe’s room. She thought he was asleep but as she lifted him into bed, she noticed his lips were blue and he was not breathing. Emergency services arrived promptly but in spite of first aid and clinical intervention, young Christopher was tragically pronounced dead that evening in hospital.
The autopsy revealed fentanyl toxicity, at 10 times the adult clinical dose. The accepted narrative at his inquest, on 11 July 2025, was that Christopher had somehow come into contact with the Durogesic 100mcg/hr TTX patch his uncle used for pain relief. The coroner identified this as “the first case of its kind in Ireland” and said he 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 that it must never happen again, it has happened again.
Amelia Grace Cooper, from Newquay, Cornwall, UK, was found lifeless in her parents’ bed on 5 June 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 was recorded as “fentanyl toxicity”.
It is very likely that Amelia had come into contact with her mother’s patch — used for pain relief — while sharing a bed. The police said “the careless actions and neglect of the prescribed mediation” was the cause of death. On the instructions of that coroner, the UK regulator — the Medicines
and Healthcare products Regulatory Agency (MHRA) — issued advice in 2018 on how to reduce the risk of such a tragedy reoccurring.
Michael Cohen, the Director and founder of the Institute of Safe Medication Practice (ISMP) in the US, makes the glaringly simple observation in Nursing 2025 that education is essential for patients using fentanyl patches to reduce the incidence of toxicity — not only to the patient, but to others, including children, who may come into contact with the patient or product.
HecitesacaseintheUSinwhicha grandmother, after giving her six-year- old grandchild a dose of ibuprofen for a neck strain, 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. The judge, on sentencing, said this must never happen again.
Mr Cohen of the ISMP documents another case where a two-year-old boy placed a fentanyl patch in his mouth after finding it on the floor of his great-grandmother’s room in a long-term care facility.
Patient and carer education
Patient education on the safe use of fentanyl patches is essential due to their unique delivery system and the drug potency, which presents particular dangers. The Patient Information Leaflet (PIL) accompanying fentanyl patches has detailed instructions on how to ensure its safe and effective use. The Summary of Product Characteristics (SPC) has more details which pharmacists and other healthcare professionals should be aware of when prescribing and supplying the drug.
Above all, there is a duty of care to patients to ensure they are aware that the drug they have been prescribed is dangerous if used incorrectly. As it is a patch formulation, it is important that its potential dangers are discussed with the patient, or their representative, at the very least on the first dispensing. However, this is currently not common practice in most UK and Irish pharmacies. Moreover, all drugs are potentially dangerous, so why make a special case for fentanyl patches?
A complex delivery system
The fentanyl patch has an adhesive side that contains the active drug. The skin should be cleaned with water before application and allowed to dry. The patch should be applied to intact, clean, and healthy skin to reduce the risk of it falling off. Skin with scars, rashes, or open wounds should be avoided. Areas with excess hair require clipping/shaving. The recommended areas to apply the patch are the chest, back, and arms. Often, patients have difficulty keeping the patch in place and most, it seems, improvise on how to manage this.
The transdermal fentanyl patch must be removed after 72 hours and replaced with a fresh patch in a new suitable location. Fentanyl is absorbed first through the top layer of the skin (stratum corneum) before reaching the blood vessels and entering the systemic circulation, where it affects target receptors.
An important consideration with the transdermal patch is the secondary reservoir of the skin
An important consideration with the transdermal patch is the secondary reservoir of the skin. After about 24 hours, significant amounts of fentanyl transfers into the epidermis, which will act as a reservoir for fentanyl — only after the epidermis has absorbed enough of the drug will it then enter the systemic circulation. This action provides a sustained level of fentanyl delivery to avoid inconsistent pain control. The secondary reservoir phenomenon allows for the continual absorption
of fentanyl until the reservoir amount descends below the threshold.
Proper disposal of used patches is vital to avoid intentional abuse and unintentional misuse by bystanders, children, and healthcare personnel.
What now?
The loss of a child in such tragic circumstances comes with highly- charged emotions. No doubt the family will be looking for answers, particularly if it was, as the coroner claims, a totally avoidable death.
What was or was not done by the professionals involved? What steps did they, or should they have, taken to ensure that this outcome was avoided? Instead of just pointing the finger of blame, it can be more productive to forensically dissect the process that led up to the tragedy so that future practice will assure, as best as possible, that it will, indeed, never happen again.
What advice beyond the current warnings in the PIL or the SPC, if any, is required? Do patients and their carers have a duty to read this information? All medicines must be kept out of the reach of children. Stating this on the medicine label passes the onus onto the patient or their carer.
The ISMP, which Michael Cohen founded 20 years ago, might offer
a helpful framework to address this incident. The ISMP process, built upon a non-punitive approach and system- based solutions, fall into five key areas: Knowledge, analysis, education, co- operation, and communication.
The Irish Medication Safety Network and the Transforming Medication Safety Group in Northern Ireland need to look at this case meaningfully, and, using an ISMP approach, come up with a sustainable proposal that can be easily implemented.
And as well as other professionals, community pharmacies need to implement changes in how this medicine is supplied in order to make sure there is never again an avoidable death like this.
Terry Maguire owns two pharmacies in Belfast. He is an honorary senior lecturer at the School of Pharmacy, Queen’s University Belfast. His research interests include the contribution of community pharmacy to improving public health.
