A woman whose GP feared she was hoarding medication was given a 28-day supply in the space of 48 hours by a Norfolk hospital just a month before she died of an overdose.
Sarah Mitchell died in her home in Lowestoft after taking a medication overdose. She was 41.
Following an inquest into her death, Suffolk coroner Darren Stewart has highlighted his fears that further people could suffer similar deaths unless communications between hospitals and GP surgeries are improved.
His concern came after it emerged Ms Mitchell had been supplied with 28 days of medication on admissions to the James Paget University Hospital on consecutive days in August 2022 - a month before her death.
Mr Stewart's report states that Ms Mitchell suffered from chronic back pain for more than 15 years, after being involved in a serious car crash.
It states that as a result she had "struggled to manage the addictive effects of pain medication" and that she would often "self-medicate" using greater doses than prescribed.
Consequently, her GP at the Rosedale Surgery restricted her medication to a weekly basis amid fears she was "hoarding" her prescriptions.
But over the period of August 3 and 4, she was twice admitted to the James Paget University Hospital, first following a road traffic collision and then following a suspected overdose.
It is reported that on each occasion she was provided with 14 days' worth of medication.
She died on September 22, 2022.
In his report, Mr Stewart wrote: "The evidence heard at inquest indicated there was no process in place whereby A&E staff could access Ms Mitchell's medical records detailing the medication she was receiving and the rationale behind the dispensing regime in place."
A spokeswoman for the Paget said: "This is a very sad case.
"The trust was not asked to supply any information before the inquest into the death of Sarah Mitchell, nor was it asked to attend the hearing.
"The trust has since received the prevention of future death report and is reviewing this case with a view to providing a full response to the coroner."
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