Amanda Hesketh · Prevention of Future Deaths report

On 27th August 2021, Alison Mutch OBE, Senior Coroner, opened an inquest into the death of Amanda Hesketh who died on 28th January 2021 at Tameside General Hospital, Ashton-under-Lyne, at the age of 53 years. The investigation concluded with an inquest which I heard on 6th and 7th June 2022, and which concluded with a Narrative Conclusion to the effect that Mrs Hesketh died as a consequence of complications of her pain relief medication. There was no evidence to suggest Mrs Hesketh misused her medication or took it otherwise than in accordance with prescribing directions in the period leading to her death.

Mrs Hesketh had a complex health history which included breast cancer with lymph-node involvement, following treatment for which she was left with severe, chronic pain. In 2019, Mrs Hesketh developed a sacral sore following a hospital admission which compounded her pain.

By this stage, Mrs Hesketh was prescribed a range of analgesic agents to try and relieve her pain in the form of fentanyl patches, fluoxetine, tramadol, amitriptyline, gabapentin, and diazepam. Individually, these medicines had been prescribed by specialists either from the Christie Hospital or from Tameside General Hospital pain clinic.

Mrs Hesketh obtained these medicines over a number of years via repeat prescription from her GP practice.

On 28th January 2021, Mrs Hesketh was brought to Tameside General Hospital by ambulance, reporting diarrhoea and vomiting of a few days’ duration. The Middle Grade doctor who assessed Mrs Hesketh considered it likely that she was suffering from gastroenteritis and arranged for her to be admitted under the care of the medical team.

Whilst still in the Emergency Department, Mrs Hesketh was found unresponsive and could not be resuscitated.

Following a post mortem examination and toxicological tests ████████, Consultant Pathologist, concluded that Mrs Hesketh died as a consequence of combined toxicity of fentanyl, fluoxetine, tramadol, amitriptyline, gabapentin and diazepam.

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1. Notwithstanding the actions the practice has taken in response to Mrs Hesketh’s death, it is a matter of concern the partnership has yet to undertake or commission a systematic review of all patients receiving repeat prescriptions of multiple analgesics and formulate individual plans for each such patient;

To the Secretary of State for Health and Social Care

2. The court heard evidence from a General Practitioner as to difficulties patients encounter in accessing services from specialist pain clinics with lengthy waiting lists often being experienced. It is a matter of concern that patients being prescribed multiple analgesics continue to receive such medicines on repeat prescription with often with little or no specialist input;

3. It is a matter of concern that GP practices who have a significant number of patients with complex analgesia regimes do not universally engage practice pharmacists to complement the knowledge of doctors and enhance the advice provided to patients.