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Investigation and inquest
On 14/12/2016 I commenced an investigation into the death of Craig Stuart Hamilton, 36. The investigation concluded at the end of the inquest on 13 June 2017. The conclusion of the inquest was Prescribed drug related death. Craig Stuart Hamilton died at ████████ Maltby on 8 December 2016 after ingesting excess Tramadol medication in an attempt to relieve his chronic pain which unintentionally led to his death from acute tramadol toxicity
Circumstances of the death
Mr Hamilton suffered a serious assault in 2009 leading to permanent and serious damage to his right leg. Part of the residual problems included chronic pain for which he received Tramadol from 2009 until the time of his death. It became clear from the evidence I heard that despite the prescribed rate (which was the maximum recommended by BNF for effective pain relief) in 2009, Mr Hamilton had effectively self medicated to the extent that he was taking almost double that dose on a regular basis from 2009 until the time of his death. Mr Hamilton died from Tramadol toxicity after taking excess amounts with the intention of controlling the pain sufficient that he could sleep during the night before working the next day. He did not take excess amounts with the intention of causing any self harm or ending his life.
Coroner’s concerns
(1) Absence of clear procedures to manage patients who routinely access larger amounts of medication than actually prescribed.
(2) Absence of clear procedures to monitor and manage patients who endeavour to obtain repeat prescriptions such that it takes them beyond the prescribed dosages.
(3) Absence of clear procedures to fully explore drug regimes and alternative forms of pain management at annual medication reviews.
(4) Consideration for improved systems for discussing with patients the implications of them attempting to exceed prescribed dosages and recording that such discussions have taken place.
Information checked against the published report and official responses