Ian Paul Wolstenholme · Prevention of Future Deaths report

On the 21st December 2017 I commenced an investigation into the death of Ian Paul Wolstenholme, concluding by way of inquest on the 6th August 2018.

Against a backdrop of pre-existing co-morbidities (including Diabetes Mellitus and associated neuropathy), chronic alcoholism and a history of heroin addiction (under long-term treatment), the deceased was found in a collapsed state at his home address on the 17th December 2017. Emergency services were summoned. Paramedics confirmed the fact of the deceased's death later the same day.

The deceased had a complex medical history and was prescribed a significant number of medications (polypharmacy), all of which were clinically indicated and prescribed with caution. At the time of his death the deceased remained under review by secondary care Diabetologists and the substance misuse service. His GP’s involvement in the management and review of his medication was therefore minimal. Whilst clinicians were of the overall view that the deceased was compliant with his medication regime, the evidence suggested that he tended to hoard some medication yet take others as prescribed. The police investigation identified large amount of medication at the deceased's home address, including 112 unused bottles of Methadone.

Whilst the deceased was on balance, afforded some degree of tolerance, his variable compliance had a material bearing upon this. Furthermore the presence of liver cirrhosis identified at post mortem examination, more likely than not, impacted upon his ability to metabolise medication resulting in a degree of accumulation. The combination of the drugs identified by way of toxicological analysis brought about a respiratory depressant effect, resulting in the deceased’s death.

There was no evidence to suggest that the deceased deliberately took any of his medication to excess, with the intent to harm himself.

The medical cause of death was:

1a) Combined drug toxicity (Codeine, Morphine, Pregabalin, Methadone)
1b) –
1c) –
2) Liver cirrhosis, Diabetes Mellitus

My Conclusion was:

‘Drug related death to which natural, pre-existing co-morbidities more than minimally contributed’.

1. During the course of the evidence, it became apparent that there is no guidance – national or otherwise - available to Clinicians such as GPs, Hospital doctors etc. on the how best to approach the prescribing of highly addictive and potentially very harmful drugs alongside one another. In this case, the deceased had been legitimately prescribed three different types of neuropathic analgesia (including Pregabalin), alongside other opiate based medications. Whilst such drugs are almost always prescribed for very good clinical reason/s, this type of polypharmacy gives rise to the potential risk of serious harm/death. I believe that guidance would help to prevent future deaths from combined drug toxicity.