Denise Sharon Parramore · Prevention of Future Deaths report

On the 20th February 2012 I commenced an investigation into the death of Denise Sharon Parramore, who was born on the 19th December 1958. The investigation concluded at the end of the inquest on the 19th November 2013. The conclusion of the inquest was that Ms Parramore died on the 19th February 2012 at ████████ Bradfield, Sheffield due to respiratory depression as a result of acute administration of Tramadol in excess of the level prescribed taken in the day prior to her death in combination with Benzodiazepines, Venlafaxine and Pregabalin.

Denise Sharon Parramore had a lengthy history of mental ill health. She was first under the care of Psychiatric Services in Sheffield in 1999. In the ensuing years there were a number of serious incidents of self-harm, and repeated indications of suicidal thoughts. On the 13th December 2011 Denise Parramore took an overdose of prescribed medication. She was subsequently discharged by the relevant psychiatric team in January 2012 when it was understood her medication included Pregabalin, Venlafaxine and Benzodiazepines. She was due to have a further appointment with the home treatment team at the end of February 2012.

Denise Parramore's General Practitioner had been prescribing Tramadol since September 2010, for chronic pain.

Denise Parramore was found deceased on the 20th February 2012.

(1) The Psychiatric Services, and in particular her Consultant Psychiatrist, was not aware, prior to Denise Parramore's death, of her being prescribed Tramadol by her General Practitioner. Concerns would have been raised, and action likely taken, if she had been aware. The Consultant Psychiatrist was not informed either by Mrs Parramore herself, nor the General Practitioner of the prescribing of the Tramadol. My concern is that there should be open, and constant two-way communication between those in primary care and secondary care such as in these circumstances.

(2) For the same reasons as given above, will it be possible for those in primary and secondary care access each other's documentation, which would likely have revealed the prescribing.