Hayley Denise Sheehan · Prevention of Future Deaths report

An investigation was commenced on 28 November 2016 and the inquest into the death of Hayley Denise Sheehan was opened on 9 January 2017. It was resumed and concluded on 26 July 2017.

The medical cause of death was found to have been:

1a. Tramadol toxicity.

The inquest concluded with a short form conclusion of ‘Accident’.

Mrs Sheehan suffered from fibromyalgia. She was a patient at the Moat House Surgery in Merstham, where she received a repeat prescription for 112 200mg slow release Tramadol tablets every two months, to be taken twice a day.

On 22 November 2016 Mrs Sheehan collapsed and died at her home address, having unintentionally overdosed on her prescription Tramadol. The medical cause of her death was found to be 1a. Tramadol toxicity. ████████ the Forensic Toxicologist, gave evidence that the levels of Tramadol present in Mrs Sheehan’s system were consistent either with her having taken 25 tablets shortly before her death or, alternatively, with her having taken her prescribed dose more than twice a day over a more prolonged period of time.

████████ a GP partner at the Moat House Surgery, told the court that during the period from 9 February to 7 November 2016 Mrs Sheehan had regularly requested her repeat prescription for Tramadol early and as a result she was able to obtain a total of 896 tablets as opposed to the 560 tablets which were envisaged by her repeat prescription, an excess of 336 tablets. With regards to the last prescription before her death, Mrs Sheehan received a prescription of 112 tablets on 7 November 2016, despite her next prescription not being due until the beginning of December 2016.

████████ told the court that patients’ requests for repeat prescriptions are dealt with by prescription administrators who receive the request and then prepare the prescription for a GP to sign. The system in place is such that in the event that a patient requests a prescription too early, the administrator should draw the request to the attention of a GP, who then makes a decision with regards to whether or not to authorise it.

Having considered the evidence, the court found that Mrs Sheehan’s requests for early prescriptions had not been identified or acted upon during the course of 2016, and that as a result she had been able to obtain a significant amount of excess medication.

████████ told the court that following Mrs Sheehan’s death the prescription administrators have been trained to highlight early requests for repeat prescriptions to GPs. He also said that new procedures have been introduced in respect of the prescription of Tramadol, and that in particular the Surgery now only prescribes it as an acute prescription, as opposed to a repeat prescription. ████████ told the court that the Surgery was considering introducing similar measures in respect of other controlled medicines.

- The procedure for issuing repeat prescriptions relies heavily upon the prescription administrators identifying and flagging early requests to GPs. As far as ████████ was aware, the software used by the surgery does not automatically identify early prescription requests.

Consideration should be given to introducing more safeguards to ensure that early requests for repeat prescriptions are identified and drawn to the attention of a GP. This should include giving consideration to whether the relevant software can be adapted to automatically identify early prescription requests.