Katie Emma Corrigan · Prevention of Future Deaths report

On 2nd February 2021, I concluded an inquest into the death of Katie Emma Corrigan who died on 9th August 2020 then aged 38.
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The medical cause of death was recorded as:
1a) Excess consumption of Codeine

I recorded a Conclusion of a drug-related death.

Mrs Corrigan had a long history of chronic pain from a neck complaint together with anxiety and depression. She developed an addiction to pain-relieving medication, notably Zapain. At inquest, it was accepted in evidence by her GP that there had been occasions when Mrs Corrigan had been prescribed too much medication and also periods when she had requested repeat prescriptions prematurely.

When the weaknesses in the GP prescribing system were identified, the GP refused to prescribe further Zapain without a discussion with Mrs Corrigan. She refused to engage with the GP and no further prescriptions were issued by the practice for Codeine or other opiates after 20/4/18.

It was also heard in evidence that Mrs Corrigan had been found to have forged prescriptions during her employment as a Practice Nurse at a surgery in Penzance in order to obtain further prescription medication illicitly. This led the NMC to strike her off the Nursing Register.

It became clear during the inquest that Mrs Corrigan had continued to source Codeine and (it is believed) Amitriptyline (as well as other prescriptions, eg, Propanolol and Modafinil) after April 2018. From packaging recovered by her GP after an admission to hospital in 2019 it is believed Mrs Corrigan obtained this from a number of on-line pharmacies, including:

Halliwell Late Night Pharmacy on 22/8/19 – Codeine Phosphate
The Independent Pharmacy on 11/11/19 – Propanolol.

It is highly likely that other on-line pharmacies may have been approached.

The identity of the doctor(s) who gave Mrs Corrigan a script for the medication, (notably Codeine or other opiates) has not been established but it was heard in evidence that her registered GP had not been contacted by any other doctors who are likely to have been approached privately by Mrs Corrigan.

The GP who gave evidence at the inquest, Dr ████████ from Bodriggy Health Centre in Hayle, stated that she had never been contacted by any other doctor considering the prescription of opiate or other medication to Mrs Corrigan. She was able to procure the medication in sufficient quantities first to require an emergency admission to hospital and latterly to result in her death.
Similarly, the registered GP was not contacted by any dispensing pharmacist checking whether the prescription was appropriate.
After Dr ████████ became aware of the two on-line pharmacies who had dispensed the medication to Mrs Corrigan that led to her admission into hospital, she attempted to raise an alert through NHS England, in order that the unsuitability of prescribing opiate medication to Mrs Corrigan could be raised with clinicians. This was sent out regionally but Dr ████████ has since been advised there is no formal procedure for circulating Patient Alerts to pharmacies on a national level.
I am further given to understand that non NHS contacts would only receive a redacted version of the alert in any event.
What seems clear is that the alert proved ineffective in preventing Mrs Corrigan from improperly obtaining sufficient quantities of opiate medication to result in her death.