Deborah Chapman · Prevention of Future Deaths report

On 20th May 2019, an inquest was opened into the death of Deborah Chapman who died on 3rd March 2019 at ████████ Altrincham, WA14 4LN, at the age of 54 years. The investigation concluded with an inquest which I heard on 31st July 2019 and which concluded with a Conclusion to the effect that Ms Chapman died as a consequence of a combination of prescribed and illicit drugs.

Ms Chapman was a long-term and open user of illicit drugs. She had ceased to inject these drugs intravenously and for some time prior to her death inhaled crack cocaine and heroin in particular.

She had significant damage to her left hip joint, which caused her significant pain and, at the time of her death, was awaiting a hip replacement operation for which she sought and was prescribed strong opiate pain relief medication.

Ms Chapman also had an underlying COPD condition, which had been the subject of hospital review and treatment in November 2018 and January 2019. The hospital were aware of and discharged Ms Chapman on each occasion with the pregabalin and oxycodone prescriptions.

Those prescriptions had already been in place prior to Ms Chapman re-joining the West Timperley Medical Centre as a patient in July 2018 and were reviewed by the practice in August 2018.

She continued to misuse crack cocaine and heroin. Ms Chapman continued to request the pain relief prescribed drugs from her GP.

On 27th February 2019, a friend moved into the house with Ms Chapman. She was able to observe that Ms Chapman was taking the prescribed medication and also using heroin. On 2nd March 2019, Ms Chapman’s daughter and mother visited her at home. It was clear to her daughter that she had taken illicit drugs. Ms Chapman’s daughter fed and bathed her mother, leaving her at about 11.00pm in the company of her friend.

Ms Chapman’s friend retired to bed with Ms Chapman and woke on 3rd March to find that Ms Chapman was unresponsive. Paramedics were called but death was pronounced at 7.06am.

A post mortem examination concluded that Ms Chapman died as a consequence of:

1)a) Combined toxic effects of heroin, oxycodone and pregabalin; and

2) Chronic obstructive pulmonary disease

1. I heard evidence from ████████ representing the West Timperley Medical Centre. He acknowledged that the known side effects of both pregabalin and oxycodone, both individually and concomitantly, presented a risk of having a depressive effect on the respiratory system. He also acknowledged that Ms Chapman’s COPD represented an underlying compromise of her respiratory system.

2. The evidence I heard from the records held at the medical centre did not reveal the extent to which any enquiry was made of Ms Chapman as to her current misuse of illicit drugs either on the occasion of her re-joining the medical practice as a patient in July 2018 or at subsequent consultations. There were clear signs of a dependence on the prescribed opiate drugs and the medical records equally revealed long-term illicit opiate misuse.

3. The evidence I heard from the medical records held at the medical centre did not reveal, beyond the admitted dependence on the prescribed medication, what enquiry had been made from Ms Chapman in relation to her continued misuse of illicit drugs or her response to those enquiries.

4. In the absence of that information, it was not possible, from the medical records, to ascertain what level of risk the continued illicit misuse of opiates posed to Ms Chapman and therefore, whether, on an informed basis, pregabalin and oxycodone were appropriate prescriptions.

5. Furthermore, the evidence did not reveal any system in place at the West Timperley Medical Centre to ensure that the information about illicit drug misuse is obtained and recorded from patients in order to ensure that an informed assessment of the risks of the concomitant use prescribed and illicit drugs could be made and reviewed.