Catherine McNamara

On 13th 2019 | commenced an investigation into the death of Catherine McNamara: The investigation concluded on the 11ih December 2019 and the conclusion was one of Narrative: Died from natural causes contributed to by toxicity of prescribed medication. The medical cause of death was Acute left ventricular failure; 1b) Coronary atherosclerosis and left ventricular hypertrophy with superimposed opiate toxicity CIRCUMSTANCES OF THE DEATH Catherine Mary McNamara was prescribed significant quantities of pain medication including opiates On 11th May 2019 she was found in bed at her home address; Post Mortem examination including toxicalogy found (hat she had a level of prescribed opiates in her system which in combination with over the counter medications had contributed to her death from acute left ventricular failure The evidence indicated that she had not taken any medication after 8th 2019 and was not seen or heard from after that date and that on the balance of probabilities she died in the early hours of 9th May 2019. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken: In the circumstances it is my statutory duty to report to you: The MATTERS OF CONCERN are as follows. The inquest heard that over a number of years amount of prescribed opiates had increased t0 a level where led her to fall asleep and fall over. After May " Mary 1a) May the they concerns were raised by her family, the General Practitioner and the clinic began to work with her t0 decrease the amount of prescribed opiates she received. This was challenging due to the high dose she had been on. At the time of her death she was on a high level (although it had decreased from the previous higher level}: The concern raised was how she had reached such high levels initially and the understanding of the impact this had on her: ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond t0 this report within 56 days of the date of this report;, namely by 7ih February 2020. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed: COPIES and PUBLICATION have sent a copy of my reportto the Chief Coroner and t0 the following Interested Persons namely lon behalf of the family, who may find it useful or of interest. am also under a duty to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me; the coroner, at the time of your response, about the release or the publication of your response by Chief Coroner: Alison Mutch OBE HM Senior Coroner 13.12.2019 pain the

Catherine Mary McNamara was prescribed significant quantities of pain medication including opiates On 11th May 2019 she was found in bed at her home address; Post Mortem examination including toxicalogy found (hat she had a level of prescribed opiates in her system which in combination with over the counter medications had contributed to her death from acute left ventricular failure The evidence indicated that she had not taken any medication after 8th 2019 and was not seen or heard from after that date and that on the balance of probabilities she died in the early hours of 9th May 2019.

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.