Angela Byrne

On gih January 2018, evidence was heard touching the death of Ms Angela Caroline Byrne. Ms Byrne had died at home on 29ih July 2017_ She was 54 years old at the time of her death: The findings of the court were as follows: Medical Cause of Death (a) Methadone toxicity II Hepatitic Cirrhosis How, when and where the deceased came by her death: Angie had a long history of relapsing and remitting drug misuse. On 29/07/2017 she took an accidental overdose of prescribed and illicit which led to and caused her death_ Conclusion of the Coroner as to the death Misadventure Drug and drugs

Ms Byrne had a long history of drug dependence and drug misuse for which she was under the care of Wandsworth Consortium Drug and Alcohol Services Her engagement in support services was erratic_ She was on a long list of prescribed medication, namely pregabalin, metformin, mirtazapine and zopiclone and had recently been started on methadone, despite a history of impulsive binge drug taking This was potentially more dangerous for her in overdose that the buprenorphine that she had been previously prescribed: She would intermittently also take drugs that she obtained illicitly for example benzodiazepines_ She was at risk of sudden death due to respiratory depression from a combination of methadone, benzodiazepines and pregabalin. On July 2017 she had been admitted to hospital unconscious after bingeing on prescribed and illicit drugs and discharged on the methadone which ultimately caused her death. The evidence was that W-CDAS who knew her better would not have prescribed this, but rather left her on drugs less risky in overdose, namely buprenorphine It would appear that were not consulted this was exacerbated by two separate systems of clinical notes for in-patients and community patients_ W-CDAS suggested that she switch back to buprenorphine rather than methadone to try and mitigate that risk but she declined. She denied any current suicidal intent. On the last of her life she appeared in normal mood and had plans to go out her partner that evening on his return from home. Sadly he returned home to her deceased and she was recognised at life extinct at 00.15 hours on the 29lh July 2017 On Friday 28h July she had taken & supervised dose of methadone in the chemist and then brought home with her the doses for Saturday and Sunday. It was found that she had taken some of this methadone on top of her daily prescription Whilst she was under the care of W-CDAS there was evidence that there was only occasional urine drug screening_ This should have occurred more often. There was also evidence taken that that she should have been under the core team to allow closer prescribing and dispensing supervision, that her suicidal ideation had not been documented and that there was no crisis plan in place_ Whilst care in keeping with her risks and complexity may have prevented her death, it could not be said on the balance of probabilities that it would have done sO. There was concern expressed in the evidence that the practitioners involved in her care were not always applying the training that they had received appropriately, for example not documenting her suicidal and self-harm risks, and not completing a crisis plan: main problem was said to be the fact that she was not under the core team, but instead had care and prescribing shared with the GP

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action. It is for each addressee to respond to matters relevant to them: