Tracy Frances MCCARTHY · Prevention of Future Deaths report

On 1 August 2023, an investigation was commenced into the death of TRACY FRANCES MCCARTHY, then aged 50 years. The investigation concluded at the end of an inquest, heard by me, on 15 May 2024.

The inquest conclusion was ‘drug-related death’. The medical cause of death was:

1a amitriptyline toxicity
II coronary artery disease

Tracy McCarthy was found deceased at her home address on 17 July 2023. She died as a result of her long-term misuse of amitriptyline.

(1) Although Amitriptyline is not generally regarded as a drug of abuse, Ms McCarthy was known to be dependent on it. She had been prescribed Amitriptyline for many years, and at one stage in or about 2022, she was regularly prescribed ████████ mg per day, which is over the maximum suggested dose in the BNF (150mg per day). In addition, the BNF provides a clear warning (as did the prescribing/records software in use at The Tredegar Practice) that Amitriptyline prescribed for depression (which it was in this case), is “not recommended – increased risk of fatality in overdose”. A GP from The Tredegar Practice told me that ████████ mg was an “unacceptable dose”.

The concern being that guidelines were not followed, particularly in relation to a patient known to be dependent and where use of Amitriptyline was not recommended for the presenting condition in any event.

(2) Following Ms McCarthy’s admission to hospital as a result of an overdose of Amitriptyline and Codeine, The Tredegar Practice received information from the hospital, making reference to the overdose. Despite this, the risk was not flagged and no alert was put on the system; as such, the prescription of Amitriptyline continued. A GP from The Tredegar Practice told me, “[the Amitriptyline] should have been stopped, but knowing [the patient] that would have been very hard to do.”

(3) Ms McCarthy’s Amitriptyline prescriptions had previously been issued on a daily basis, to mitigate the risk of overdose. However, following her admission to hospital (mentioned above) a GP at The Tredegar Practice took the decision to reduce the dose slightly, but transfer to monthly prescriptions, thereby allowing Ms McCarthy access to 28 days’ worth of Amitriptyline all at once. A GP from The Tredegar Practice told me that they thought this was “risky” but said that the GP who made that decision was not familiar with the patient and maybe wouldn’t have known the rationale for daily prescriptions. They also told me that the Practice was probably “over-reliant on the knowledge of particular doctors that treated her.”

The concern is that too great an emphasis was placed on the knowledge of a few individuals, which led to acknowledged risks not being put in the records in a way that would alert any practitioner to them.