Kathryn Mary Barrow · Prevention of Future Deaths report

On 3rd July 2019, I opened an inquest into the death of Kathryn Mary Barrow, who was found dead on 7th March 2019, aged 59 years. The investigation concluded at the end of the inquest which I heard on 23rd August 2019.

The evidence heard in court did not therefore confirm by what means Kathryn Barrow came by her death. At the end of the inquest, I therefore recorded an Open conclusion.

Kathryn Barrow was found dead at her home on 7th March 2019. She had a long history of mental illness, and had received care and treatment for bipolar affective disorder both by mental health specialist services and doctors at the practice. Mrs Barrow was prescribed a variety of medication, which she supplemented with illicit drugs.

A post mortem examination did not establish a medical cause for Mrs Barrow’s death. Toxicological tests suggested Mrs Barrow had used Diazepam, Cannabis and Olanzapine in the period leading up to her death. Whilst such tests did not identify any evidence of overdose, their results must be regarded with circumspection due to the effects of decomposition.

An investigation by Greater Manchester Police concluded there were no suspicious circumstances surrounding Mrs Barrow’s death.

1. Having claimed this has been advised by her Consultant Psychiatrist, Mrs Barrow has obtained short course prescriptions for Diazepam from the surgery apparently without further documentation being received from mental health services to confirm this, or without further checks being made by the GP;

2. From the evidence heard at court, doctors at the practice prescribing Diazepam to Mrs Barrow do not appear to have sought to ascertain whether or not she may have access to this medicine illicitly;

3. The court heard evidence that the practice has not recently undertaken any review of its approach to prescribing Diazepam.