GPs have been absolved of blame over the death of a man who was given multiple prescriptions in the days before he died at a Salvation Army hostel in Belfast.
Coroner Brian Sherrard said he did not want to criticise the doctors. "I would not like anybody to in any way judge the GPs harshly, I don't think that would be right," he said.
But he expressed his concerns about a system "full of deficiencies" that allowed the homeless addict just out of prison to get drugs from three doctors at two practices.
Mr Sherrard said: "Had he so wished he could have gone to any number over the eight days – it is a very worrying state of affairs for the vulnerable."
He added: "What I intend to do is to ask specifically the minister for health to consider options to minimise the risk of this being repeated."
Sean Mooney, 30, died from pneumonia caused by an overdose of Diazepam, Temazepam and Dihydrocodeine. He had become addicted after being prescribed the drugs after paramilitary attacks, including a shooting, when he was a teenager.