Lakhminder Kaur

On the 10 November 2017, I commenced an investigation into the death of Mrs Kaur. The investigation concluded at the end of the inquest on 15 January 2018. The conclusion of the inquest was a short narrative conclusion of suicide.

The cause of death was:

1a Hanging

i) Mrs Kaur had a medical history including Diabetes and also recurrent depressive disorder. She was also taking anti-depressant medication and zopiclone for insomnia. ii) She had increasingly become reliant upon zopiclone to help her cope with anxiety as well as insomnia and had been taking the medication for around 5 years. iii) She had a meeting with Speciality Doctor Psychiatrist on the 29 September 2017 and a recommendation was made to stop the zopiclone to avoid an accidental overdose. iv) However, after concerns raised by the family and further representations made to her GP, she did continue to receive zopiclone and this was tapered to reduce her levels over several weeks. v) On the 5 November 2017 she sadly took her own life by hanging at her home with a ligature around her neck

[IL1: PROTECT]

1. There appears to have been little or inconsistent management of patients on long term zopiclone medication and lack of communication between the GP and secondary mental health services in managing medication. In light of this, you may wish to consider working in collaboration with the Black Country Partnership NHS Trust to review your systems and procedures in identifying long term users.