Dr Polly Joanne Drew · Prevention of Future Deaths report

On the 9th March 2018, I commenced an investigation into the death of Dr Polly Joanne Drew, aged 35 years. The investigation concluded at the end of the inquest on 30th November 2018. The conclusion of the inquest was Suicide. Dr Drew took her own life by injecting herself with an anaesthetic agents (Propofol and Atracurium) acquired from the medical centre at Donnington Racetrack the day prior to her death. She had been working there as the Duty Doctor, employed by Central Medical Services, a Private Medical Service that provides medical cover for a variety of events such as motor racing.

Dr Polly Drew was known to have Bipolar Disorder, a diagnosis made in 2009. She had made a number of previous self harm attempts. She had been found to have needles and syringes in her possession in an operating theatre in April 2012, whilst working as an Anaesthetic trainee at Nottingham University Hospital NHS Trust (NUH), and then in July 2012 injected herself with Remifentanil, an opioid anaesthetic drug, again in the Operating Theatre, leading to a respiratory arrest.

In 2016 she developed renal failure following a collapse, secondary to significant alcohol intake and likely other drugs. Thereafter she struggled with low mood, but was able to work as a GP trainee in a Practice in Nottingham. Her working hours and patient contact was limited, with no out of hours evening or overnight work, adaptations that were made by her Supervising Trainers on the Nottingham GP Training scheme.

The GMC were involved in assessing her Fitness to Practice from 2012 to 2016.

Her GP, treating Consultant Psychiatrist, and the General Practice where she was working, were unaware of her working additionally for Central Medical Services.

Dr Drew was recommended to work at Central Medical Services by a ████████, a Consultant in Anaesthetics/Critical Care. I understand she was known personally to him. This was a verbal recommendation, with CMS not taking up any written references, nor completing a DBS check prior to Dr Drews employment

1. The recruitment process for the appointment of a Doctor to a position of such significant responsibility, with access to anaesthetic drugs, is completely inadequate. None of the above appears to have been known to ████████ when Dr Drew was appointed. Dr Drew worked alone, putting herself and members of the public, for whom she had medical responsibility, at potential significant risk.