Source · Prevention of Future Deaths

Sarah Brady

Ref: 2021-0224 Date: 5 May 2021 Coroner: Joanne Lees Area: Black Country Responses identified: 1 / 1 View PDF

A hospital issued an excessive prescription to a high-risk patient with an overdose history, overriding GP-imposed limits and duplicating medication, which potentially enabled stockpiling and increased the risk of overdose.

Date 5 May 2021

56-day deadline 2 Sep 2021 est.

Responses identified 1 of 1

Alcohol, drug and medication related deaths Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Other related deaths

Coroner's concerns

AI summary

View full coroner's concerns

(1) Mrs Brady had a long history of Chronic pain, mental health problems and informal admissions in Psychiatric hospitals. She had a recent history of intentional medication overdose in March 2020 and erratic compliance with her medications.

(2) Due to the above, Mrs Brady’s GP was only issuing 7 day prescriptions due to her high risk of overdose in order to limit medication availability. This included amongst others.

(3) Mrs Brady had already been issued with a prescription by her GP on 14/7/20 for her regular prescription medication; (4) The inquest heard evidence that following a hospital admission in early July 2020, Mrs Brady was medically fit for discharge on 15/7/20 and a prescription was issued by the Sandwell & West Birmingham Hospital Trust for 14 days of (4) It was unclear from the evidence whether the prescription had actually been fulfilled by the hospital. I am concerned that Mrs Brady was issued with a prescription in excess of 7 days and for medication that had already been prescribed to her by her GP only the previous day and against a background of overdose and erratic compliance with her medications; (5) The levels of found as a result of qualitative testing appeared to be well in in excess of her prescriptions and there was evidence that Mrs Brady may have been stockpiling medication. It is possible that the additional prescription, if supplied may have formed part of the medication taken by way of overdose.

(6) I heard at inquest that another similar prescription issued on 28/7/20 following a further admission had NOT been fulfilled.

Responses

1 respondent

Sandwell General Hospital NHS / Health Body

28 Jun 2021 PDF

Disputed

The hospital disputes that Mrs. Brady was oversupplied with medication, stating that medications were generally supplied for short durations and the dispensed Aspirin was within agreed limits. (AI summary)

View full response

Dear Mrs Lees,

RE: Regulation 28 Report – Sarah Brady

I am in receipt of your Regulation 28 Report following the Inquest and your ruling on 5 May 2021, in respect of the late Mrs Sarah Brady.

During the collation of information for the inquest, it was recognised that the frequent attendance and associated discharge processes, including provision of medication, may highlight that there might be an oversupply to an already vulnerable person. I am sorry we missed the opportunity to provide you with this evidence. This was, in fact, not the case.

You will see from the attached list that, apart from the Aspirin, dispensed on 29 July 2020, medications were supplied for 7 days, 5 days or were not dispensed at all, instead giving back her own medications. The Aspirin was a new medication so was supplied to the level agreed with the CCG and in total only provided 2.1g, where the maximum daily dose for pain control is 4g.

I understand from those present at the inquest hearing, that Mrs Brady was known to stock pile medications, clearly both we and her GP were managing the complexity of providing medications to treat her ailments, at the same time as trying not to over provide medicines to a clearly vulnerable person.

Given the information we provided at the Inquest and the attached evidence, I believe we were not over supplying Mrs Brady.

My colleague, , Deputy Director of Governance, would be best placed to provide advice or further details on our actions. She can be contacted on or through

Report sections

Investigation and inquest

On 6/11/20 I commenced an investigation into the death of Sarah Brady dob 26/1/45. The investigation concluded at the end of the inquest on 5/5/21. The conclusion of the inquest was Suicide. The medical cause of death was recorded as 1a) Multiple Organ Failure, 1b) overdose 2) Stroke and Depression.

The inquest found and recorded the following facts;

On 4/8/20 the deceased, a 75-year-old lady was admitted to hospital having been found unresponsive following a presumed overdose of . Ante mortem toxicology tests revealed significant concentrations of

. Despite treatment with antidotes and antibiotics, she continued to deteriorate and went into multi organ failure and sadly passed away in hospital on 8/8/20. Mrs Brady had a historical diagnosis of depression and PTSD and more recently functional neurological disorder with longstanding chronic back pain. She had a history of intentional medication overdose in March 2020 and had recently self-discharged from hospital 3 days before this admission. Mrs Brady was in possession of a significant amount of prescription medication at the time of her death and there was evidence of recent deterioration in her mental and physical health in the weeks leading up to her death.

Circumstances of the death

Mrs Brady was a 75 year old lady admitted to City Hospital, Birmingham on the evening of 4/8/20 having been found unresponsive at home following a presumed overdose ( ). She had Multiple recent hospital admissions with back pain, abdominal pain, headache and photophobia and had Self-discharged from hospital on 01/08/2020 following an admission with back pain; underwent an MRI spine and was discharged with analgesia. A urine toxicology screen from was positive for , . Blood Paracetamol levels were less than 10 mg/l and blood salicylate levels were less than 50 mg/l. Her blood ethanol level was < 100 mg/l (not detectable). She was treated with Naloxone and antibiotics for an aspiration pneumonia. Quantitative toxicology results from admission showed , and . All of these were consistent with the diagnosis of significant overdose. Given the response to extra doses of antidote the rate of the Naloxone and Flumazenil infusions were increased. Mrs Brady deteriorated into multi organ failure despite treatment and on the afternoon of 8/8/20 the Naloxone and Flumazenil infusions were discontinued at 12:57 hours and Mrs Brady passed away in hospital shortly afterwards.

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Report details

Reference: 2021-0224
Date of report: 5 May 2021
Coroner: Joanne Lees
Coroner area: Black Country

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Sep 2021 (estimated).

Sent to

Sandwell and West Birmingham Hospital Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.