Ms Karen Redding · Prevention of Future Deaths report

On the 28 March 2021, I commenced an investigation into the death of Ms Karen Redding. The investigation concluded at the end of the inquest on 28 October 2021. The conclusion of the inquest was a short form conclusion of open conclusion:

The cause of death was:

1a Multidrug Toxicity

II Ischaemic Herat Disease, Diabetes, Chronic Kidney Disease

i) Ms Karen Redding (KR) was first started on morphine sulphate solution (Oramorph) on 19 November 2019.

ii) The oramorph medication was for management of pain relief after a leg amputation. Her initial dose was████ to be taken up to four times daily.

iii) On 6 August 2020 the dose of Oramorph was then increased to ████████ times daily when KR reported worsening pain from her stump.

iv) The last prescription for Oramorph issued by the GP practice was on 13 January 2021. Her previous supply had lasted since the 3 November 2020 and she told her GP that she was using the Oramorph for 'breakthrough pain'.

v) On the 24 March 2021, KR requested that a member of the care staff pass her a box that was placed near her in her room. This box contained a bottle of oramorph medication. KR subsequently drank around ████████ of oramorph.

vi) Later that afternoon further care staff visited, and KR told them she had taken “a little too much” oramorph.

vii) She became increasingly drowsy and sadly died from the fatal overdose.

1. Evidence emerged during the inquest that KR was handed the oramorph medication by the care staff upon her request. It appears that there was no check made of the contents of the box.

2. KR subsequently disclosed that she had taken an excess of oramorph solution.

3. Although, she declined any help and said she would prefer to rest and “sleep it off”, it may well have been appropriate to have her seen by a Doctor.