Investigation and inquest
On 1st October 2024 I commenced an investigation into the death of Louise Danielle ROSENDALE. The investigation concluded at the end of the inquest on 17th March 2025. The conclusion of the inquest was accidental death. The medical cause of death was 1a) Multiple drug toxicity and Pneumonia.
Circumstances of the death
Louise Danielle Rosendale was prescribed long term opiates for pain following previous surgery. On 24th September 2024 she was found unresponsive at ████████. A post-mortem found she had died from a combination of multiple drug toxicity and pneumonia.
Coroner’s concerns
THE INQUEST HEARD EVIDENCE THAT Louise Rosendale had been prescribed opiates for many years despite the risks associated with long term opiate prescribing. The evidence before the inquest was that there had been very limited attempts to review the long term prescribing of opiates to her. The inquest was told that she had been identified as a patient on a long term opiate prescription in 2022. The next action had been a pharmacy review in July 2024.There was no evidence of long term detailed planning or oversight of these patients within the practice