Ms Penelope Benton · Prevention of Future Deaths report

On the 20 September 2017, I commenced an investigation into the death of the late Ms Penelope Benton. The investigation concluded at the end of the inquest on 31 October 2017. The conclusion of the inquest was a short narrative conclusion of suicide.

The cause of death was:

1a Tramadol Overdose

i) Ms Benton had a complex medical history including diagnosed paranoid schizophrenia and also a history of self-harm including drugs overdoses. She also had a stoma fitted following an obstruction to her bowel. This had caused significant pain over a number of years.

ii) On the 22 September 2016 she was admitted to Bushey Field Hospital after a relapse and sectioned under S3 Mental Health Act. She disclosed to her care co-ordinator on the 26 September 2016 that she had taken an overdose of 60 Tramadol tablets and that she had had enough of her pain and wanted it to go away.

iii) After making improvement she was discharged with support in the community on the 18 October 2016. The discharge note did not record any details of the Tramadol overdose and the GP continued to give her Tramadol medication for pain relief.

iv) On the 12 July 2017, Ms Benton took a significant quantity of Tramadol tablets (40.4mg/L) and fatalities have been associated with concentrations of greater than 6 mg/L.

v) Sadly, she was pronounced deceased on the same day and the cause of death was later confirmed as Tramadol overdose.

1. Evidence emerged during the inquest that the General Practitioner wasn’t made aware of the previous tramadol overdose on the discharge letter from Hospital.