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Investigation and inquest
On 13th September 2021 I commenced an investigation into the death of Aoife Rose McAdam, aged 19. The investigation concluded at the end of the Inquest on 24th March 2023. The conclusion of the Inquest was that Aoife’s death was a misadventure. The medical cause of death was 1a) Cardiac Arrest; 1b) Intentional Propranolol Overdose; 2) Anxiety & Mood Disorder. The inquest found that the overdose had been taken as an impulsive act, in respect of which Aoife sought help, the provision of which was delayed.
Circumstances of the death
Aoife died on 4th September 2021 in Leeds General Infirmary where she had been brought at 0823 hours having taken a significant overdose of propranolol at about 0430 hours. She rang the Crisis Team and NHS 111 within 30 minutes of taking the overdose. There were two opportunities missed to send her an ambulance sooner which would on the balance of probabilities have meant her reaching hospital at least two hours earlier than she eventually did.
Coroner’s concerns
(1) Aoife was prescribed propranolol by a locum GP at Burton Croft Surgery on 18th March to control the physical symptoms of anxiety by a locum GP at Burton Croft surgery. The prescription comprised 84 tablets (a maximum of three tablets to be taken daily as an as required medication). This was the only occasion on which she was prescribed propranolol.
(2) On the morning of 4th September 2021, when she took her overdose ████████
(3) On 12th August 2021, in a consultation with another GP at Burton Croft Surgery, Aoife reported that the Propranolol was not helping her and, following discussions and advice, she said she wished to switch to the antidepressant Sertraline, which was prescribed.
(4) In evidence, the GP present at the second consultation agreed that Aoife should have been advised safely to dispose of any propranolol tablets remaining from the earlier prescription by, for example, returning them to a pharmacist. Aoife was not so advised.
(5) Aoife, who by reason of her being prescribed an antidepressant was known to be in a potentially fragile mental state, was left in possession of a significant quantity of a medication known for its potential cardiotoxicity when taken in overdose and which she had stated she no longer wanted or needed.
(6) The primary cause of her death was an overdose of that potentially cardiotoxic medication, which she should not have had in her possession by 4th September 2021.
Information checked against the published report and official responses