'Shambles' over Graham Saffery's prescription drug death Published duration 20 January

image copyright Family Photo image caption Graham Saffery died as a result of taking a combination of drugs prescribed to him

The family of a man who died from a prescription drug overdose have said communication between those that cared for him was a "shambles".

Graham Saffery's death in Bedford in June 2018 was caused by drugs known to carry a risk of over-sedation.

His family repeatedly raised concerns about the drugs he was prescribed.

A coroner said there was "a lack of effective communication on even a most basic level between the various parts of the NHS" caring for the 48-year-old.

Father-of-two Mr Saffery worked as a driver for a car dealership. In November 2015 he was involved in a crash on the A1 and about a year later was prescribed oxycodone to deal with the pain.

His brother, Glen, said being unable to work following the crash "took his identity away from him" and left him "a bit lost".

Mr Saffery, a former youth rugby player for London Irish, was diagnosed with depression in January 2018 and was prescribed amitriptyline.

image copyright Saffery family image caption Graham Saffery's father Brian (pictured) said communication between NHS departments in his son's death "was just non-existent"

His brother said from the start of 2018 it was "it was clear he was deteriorating" and struggled with balance and hallucinations.

And the inquest heard his pharmacist had concerns Mr Saffery looked "a bit drugged" and seemed confused.

But Emma Whitting, senior coroner for Bedfordshire and Luton, said in conclusions seen by the BBC the concerns "did not appear to have been communicated" to a community mental health doctor, who doubled his amitriptyline dose on 23 May.

Four days later Mr Saffery was taken to Bedford Hospital after collapsing on the street and, despite believing his condition had most likely been the result of over-sedation from the drugs, he was not referred to the psychiatric liaison team.

The coroner said it was "likely that the amitriptyline would not have been restarted" if a referral had been made.

image caption Graham Saffery had been in Bedford Hospital weeks before his death

The pharmacist again expressed concern about Mr Saffery to his GP on 13 June and the family also expressed similar concerns at the practice the next day but his medications remained unchanged.

Mr Saffery was found dead at his flat on 19 June by his father Brian and brother Glen, three days after last speaking to his family.

They have now called for better communication between NHS departments and more effective monitoring of prescriptions.

His father said: "In my opinion it was a shambles from beginning to end and the communication was just non-existent.

"When we heard it at the coroner's court - it was farcical and at the end of it all there's someone dead."

image copyright Contributed image caption Graham Saffery had been a rugby player for London Irish at youth level

Glen Saffery added: "The overriding feeling from us is that we kept on asking for help for him and he kept on going to different professionals and should have been given help and just wasn't."

East London NHS Foundation Trust, which had been involved in Mr Saffery's mental health care, said it had "listened, learnt and made changes where necessary" following an investigation into his death.

Bedford Hospital NHS Trust said in a statement it was "committed to creating an effective culture of learning where we listen to, and where necessary, investigate patient experiences".

"The trust has responded in full to the coroner's report comments and continues to offer the patient's family our sincere condolences and sympathy for their loss."

Mr Saffery's GP practice, Queens Park Health Centre, Bedford, said: "[The practice] is committed to learning and where necessary, changes have been implemented to reduce the risk of anything like this happening again."