Jessica Mary BIRKHEAD · Prevention of Future Deaths report

On 31 July 2015 I commenced an investigation into the death of Jessica Mary BIRKHEAD aged 30 years. The investigation concluded at the end of the Inquest on 20 May 2016.

The conclusion of the Inquest gave a Medical Cause of Death of:

“1a. Acute Hepatic Necrosis (probably due to Paracetamol toxicity) and Pregabalin overdose.”

The Narrative Conclusion was given stating:

“Jessica Mary BIRKHEAD died on 28 July 2015 from Acute Hepatic Necrosis (probably due to Paracetamol toxicity) and Pregabalin overdose, a drug not prescribed for her, at a time when her judgement was impaired as a result of her existing medical conditions”.

Mrs Birkhead was born with Down’s Syndrome (mosaic variety) and associate learning difficulties. She also suffered from a depressive illness, with possible psychosomatic symptoms secondary to psychosocial stressors.

On the 28th July 2015 Jessica’s husband called emergency services when he found his wife unconscious. Jessica was taken to the Royal Devon & Exeter hospital where she died at 14.40 hours the same day. The pathologist concluded Jessica had ingested a large quantity of Paracetamol but was uncertain as to whether this was potentially a build-up of that drug over a prolonged period. She had also ingested a large number of Pregabalin tablets, a drug not prescribed for her, but her mother-in-law who lived in the same household.

1. Although Jessica had been referred to a Consultant Psychiatrist in learning disability, the other support services offered to Jessica were main stream adult services, Jessica’s mother, a GP, is of the view that they were not equipped to deal with someone of Jessica’s intellectual disabilities.

2. Perhaps Jessica’s case could be looked at to consider the appropriate pathway for others in the future in a similar situation to Jessica to give appropriate support and care at a level appropriate taking into account any learning difficulties and associated medical problems.