Source · Prevention of Future Deaths
Amanda Spark
Ref: 2018-0109
Date: 19 Apr 2018
Coroner: Rachael Griffin
Area: Dorset
Responses identified: 0 / 1
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Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential issues with medication management and oversight.
Date
19 Apr 2018
56-day deadline
12 Aug 2018 est.
Responses identified
0 of 1
Coroner's concerns
Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential issues with medication management and oversight.
View full coroner's concerns
In the circumstances it is my statutory to report to you: Mary May duty
During the inquest evidence was heard that: Mrs Spark was lady who suffered with her mental health and she had been engaging with Dorset Healthcare University NHS Foundation Trust (DHUFT) since 2009. On the 25th August 2017 she was admitted to the Royal Bournemouth Hospital, Bournemouth having taken an overdose of medication. She was assessed by the Psychiatric Liaison Team who are part of DHUFT and was discharged to the Crisis team within DHUFT . She was seen daily by the Crisis team and during the visits decided to change her medication regime
During the inquest evidence was heard that: Mrs Spark was lady who suffered with her mental health and she had been engaging with Dorset Healthcare University NHS Foundation Trust (DHUFT) since 2009. On the 25th August 2017 she was admitted to the Royal Bournemouth Hospital, Bournemouth having taken an overdose of medication. She was assessed by the Psychiatric Liaison Team who are part of DHUFT and was discharged to the Crisis team within DHUFT . She was seen daily by the Crisis team and during the visits decided to change her medication regime
Report sections
Investigation and inquest
On the 8th September 2017, an investigation was commenced into the death of Amanda Spark, born on the gth 1971. The investigation concluded at the end of the Inquest on the 6th April 2018 The Medical Cause of Death was: 1a Combination of multiple drugs (Codeine, Zopiclone, Amitriptyline and Mirtazapine) and ethanol intake The conclusion of the Inquest was suicide:
Circumstances of the death
On the 3rd September 2017 the deceased, who suffered with depression, was found in collapsed and unresponsive condition in the bedroom at her home address at Flat 3 Cedra Court; Westby Road, Bournemouth.
Action should be taken
In my opinion urgent action should be taken to prevent future deaths and believe you and/or your organisation have the power to take such action:
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Report details
- Reference
- 2018-0109
- Date of report
- 19 April 2018
- Coroner
- Rachael Griffin
- Coroner area
- Dorset
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Aug 2018 (estimated).
Sent to
- Dorset University NHS Trust