Kathleen Gabrielle Bamforth · Prevention of Future Deaths report

On 24/8/17 I opened an inquest into the death of Kathleen Gabrielle Bamforth who, at the date of her death was aged 59 years old. The inquest was resumed and concluded on 12/6/18
I found that the cause of death to be: -
1a. The effects of clomipramine Toxicity

I concluded with a narrative conclusion as follows:
On 28/5/17, Kathleen Gabrielle Bamforth, who had a history of depression and alcohol misuse, was found to have died at her home address. At post mortem her blood was found to contain fatal quantities of her prescribed medication clomipramine (3.1 ug/ml) along with therapeutic amounts of her prescribed naproxen (21.2ug/ml), tramadol (0.87 ug/ml) and pregabalin (2.3 ug/ml). Although there is no evidence to suggest that she took an overdose deliberately or inadvertently, the reason for the toxicity of the clomipramine toxicity remains unclear

At approximately 5.40am 28/5/17, Kathleen Bamforth was found unresponsive in the living room of her home address. Immediate attempts were made to resuscitate her, but upon the arrival of the paramedics she was confirmed to have passed away. She had been prescribed clomipramine for several years by her GP which was being properly monitored although the GP had no clinical cause to check the levels by way of a blood test. During the inquest ████████ the toxicologist gave evidence and he was unable to confirm whether the toxicity was acute or chronic and that the circumstances of how she developed the toxicity remained unclear.

• To review current practice guidelines with respect to the prescription of clomipramine
• To consider the merits of routine blood screens in patients prescribed with long term use of clomipramine.