Michael Anthony Tarratt · Prevention of Future Deaths report

On 12 February 2014 I commenced an investigation into the death of Michael Anthony Tarratt DOB 3 January 1968. The investigation concluded at the end of the inquest on 10 March 2014. The cause of death was multiple drug toxicity and my conclusion was this was an accidental death.

Mr Tarratt had a long known history of poly drug and alcohol abuse, and was receiving treatment for his opioid dependence. He was prescribed methadone to assist with withdrawal. It appeared that Mr Tarratt was motivated to try and reduce his dependency and seemed to be positive and forward thinking at the time of his death. He was seeing his GP and drug worker regularly in the months leading up to his death. Mr Tarratt was found deceased at his home address from the effects of multiple drug toxicity; there was no evidence of intent to take his own life.

(1) Despite Evidence from the Drug and Alcohol team that it was appropriate to update the relevant GP every 3 months, or at least every 6 months, it was accepted on this occasion that no contact had been made for 18 months. Consideration should be given to more regular contact between the services providing treatment.

(2) Despite Evidence that the GP prescription of tramadol (for knee pain) was inappropriate for an opiate dependent patient, no contact was made with the GP surgery and it was left to the patient to tell his GP. There was no evidence to suggest that Mr Tarratt did this. Consideration should be given to routine exchange of information regarding prescriptions between services, to avoid one agency counter-acting the treatment of the other. Consideration should be given to the appropriateness of asking the patient to be responsible for this communication.