Kimberley Holden · Prevention of Future Deaths report

On the 28th February 2015, I commenced an investigation into the death of Kimberley Holden, aged 27 years. The investigation concluded at the end of the inquest on the 23rd March 2017. The conclusion of the inquest was Narrative as follows:

On the 26th November 2014 Kimberley Holden died from Oxycodone toxicity. This drug had been prescribed for pain arising from her neurological condition. The dose prescribed for her, was significantly higher than intended, and contributed to her death.

Kimberley had a chronic neurological condition, that of Devics Disease, similar to Multiple Sclerosis. She was under the care of the Neurology team at Derby Hospitals NHS Trust. She suffered with chronic pain.

Her GP prescribed a dose of a strong Opiate, Oxycodone, for pain, at a concentration that was 10 times the intended dose. An alert on the prescribing screen, advising that the medication was a concentrated solution was overridden.
The suggestion to prescribe this medication, which was used rarely in general practice, came from a Specialist Nurse working for a different Health Trust, that of Derbyshire Community Health Services. This nurse did not discuss her suggestion of Oxycodone with the Hospital team, who were advising on all other medications.

Further detail of my findings in relation to these issues is included in the written judgment in this case, which is attached to this document.

1. The continuing risk of unsafe prescribing of controlled drugs by the Ivy Grove Surgery, and the limited understanding of the duty to report serious prescribing incidents.
2. The continuing risk of poorly coordinated management and prescribing in neurological patients under the care of both DCHS and the Derby Hospital

During the Hearing, I heard evidence in relation to these matters, and the oral evidence and documents went some way to addressing the concerns raised.