Mrs Christine Forbes · Prevention of Future Deaths report

On the 10ᵗʰ February 2020, I commenced an investigation into the death of Mrs Christine Forbes. The investigation concluded at the end of the inquest on 22 September 2020. The conclusion of the inquest was a short form conclusion of suicide.

The cause of death was:

1a Combined Oxycodone and Zolpidem Toxicity; and

II Coronary Artery Atherosclerosis

i) Mrs Forbes was a 72 year old woman who had a history of operation induced incontinence and pain management. She broke her leg in 2016 and this required treatment as well as pain management. She was prescribed oxycodone. In May 2017, having stockpiled her oxycodone, she took an intentional overdose. This was unsuccessful.

ii) On the 29 September 2019 she again broke her leg. She was seen by a consultant at the Royal Derby Hospital. She was prescribed oxycodone. She was then prescribed oxycodone, by her usual GP surgery, the Bollington Practice, twice over the course of the following two months.

iii) She registered with the Ashbourne Surgery in Derby on the 28 November 2019. This surgery had no information about Mrs Forbes. It is standard practice that, once a patient registers with a particular surgery, a request for their medical notes is made. This request is made to Primary Care Support England. It can take a significant amount of time for these to be sent. In relation to Mrs Forbes, her medical history and notes did not arrive with Ashbourne Surgery until shortly before Mrs Forbes passed away.

iv) On the 11 December Mrs Forbes was prescribed oxycodone by Ashbourne Surgery’s Pharmacist. This was done without the pharmacist having access to relevant information regarding Mrs Forbes, namely, her previous stockpiling and misuse of oxycodone and any previous episodes of self-harm or suicide.

v) On the 2 February 2020 Mrs Forbes took oxycodone and zolpidem in quantities that caused her to pass away. She left a suicide note and her last will and testament for her husband to find. This was the same manner in which she had tried to take her own life in May 2017.

vi) It was accepted, at inquest that the prescription of the oxycodone to Mrs Forbes was completed on the 11 December 2019, by Ashbourne Surgery’s Pharmacist. This was done without the Pharmacist having access to the medical notes of Mrs Forbes. These would have contained her previous medical history and would have allowed for a more meaningful review before the decision to prescribe was made.

vii) It was stated in evidence that it is usual for a new patient to register at a GP practice and, for the notes for that patient to follow a significant time after the registration.

1. That when patients register at GP surgeries (across England) they do so without their medical notes and history. This material can take a significant amount of time to be sent to a GP practice after a request is sent to Primary Care Support England. Doctors and other medical practitioners are therefore treating and prescribing in situations where a full medical history is not known.