Kathleen Cornthwaite · Prevention of Future Deaths report

On 6th December 2013 I commenced an investigation into the death of Kathleen Cornthwaite aged 76. The investigation concluded at the end of the Inquest on 3rd June 2014. The conclusion of the Inquest was that Kathleen Cornthwaite died of cardiorespiratory failure due to combined tramadol and fluoxetine toxicity in the circumstances of which being that she had been admitted to Pendle Community Hospital when following a fall on 2nd December 2013 in which she sustained an injury to her ribs her prescription for tramadol was increased. The doctor prescribing the tramadol failed to take into account her age, size and the effect of other medicines that were being prescribed such that she suffered a fatal overdose, the conclusion being that of medical misadventure.

Whilst an inpatient at Pendle Community Hospital Kathleen Cornthwaite was being prescribed 15mg of tramadol four times a day together with fluoxetine for depression. On the 2nd December 2013 she fell sustaining a rib injury and at that time the dose of tramadol was increased to 50-100mg to be taken four times daily. The drug chart failed to indicate whether the dose dispensed was 50 or 100 such that during the period from the 2nd to the 4th December the dose of tramadol dispensed could have been anything between 250mg per day and 400 mg per day. For a person over the age of 75 the maximum dose is 300mg per day.

1. That the drug chart failed to indicate the precise dose of tramadol dispensed.

2. That the doctor prescribing was not aware of the maximum dose of tramadol for somebody over 75 years of age and failed to take into account her size and frailty.

3. There was no system in place such that the doctor would appreciate the fact that in prescribing tramadol he or she ought to have had regard to other medicines being prescribed particularly in this case fluoxetine.