Carly Marie GORDON · Prevention of Future Deaths report

On 2nd June 2016 I commenced an investigation into the death of Carly Marie GORDON (Mrs Gordon) date of birth 11th April 1980. The investigation concluded at the end of the Inquest on 19th July 2017. The conclusion of the inquest was that Mrs Gordon took her own life while suffering from a depressive disorder and the effects of withdrawal from Benzodiazepines.

On the 20th May 2016 Mrs Gordon was admitted by ambulance to the A & E department of North Devon District Hospital, Barnstaple, North Devon, following a failed attempt on her own life. She was then admitted onto Ocean View psychiatric ward at the same hospital. Mrs Gordon was not under section but a voluntary patient and after initial assessments she agreed a treatment regime with the consultant psychiatrist and the mental health team. She was allowed to be collected by her parents during the day but return to the ward at night. On the 27th May 2016 after review with her consultant psychiatrist Mrs Gordon was collected by her mother and taken home. Later that same day she was found hanging in the garage of her home which was situated a few doors away from her parent's property. During the course of the Inquest it became apparent Mrs Gordon had a long history of anxiety and depression for which she received various medication including Lorazepam which had first been prescribed for her in August 2014. There had been attempts to reduce this drug from February 2016. Mrs Gordon found this difficult eventually attending a private clinic to manage the withdrawal shortly before the 20th May 2016. Although not taking this drug at the time of her death her consultant psychiatrist believes she was suffering from withdrawal state from Benzodiazepines which contributed to her anxiety and agitation as well as experiencing somatic symptoms. In the opinion of the consultant psychiatrist the long term use of Lorazepam was a contributory factor in Mrs Gordon's death.

(1) The long term use of shorter acting Benzodiazepine instead of longer acting Benzodiazepine in accordance with the British Association of Psychopharmacology Guidelines should be followed when patients are prescribed this drug to avoid dependence.

(2) All patients who receive this drug for an extended period of time should be reviewed by their medical advisors to reassess their suitability for the long term use of this particular medication.