Nadine Brookes-Walker · Prevention of Future Deaths report

On the 5th May 2015 I commenced an investigation into the death of Nadine Brookes-Walker (age 32 years), for whom the cause of death was given as being that of 1a) Fentanyl Toxicity and at an Inquest held at Rochdale Coroners Court Heywood on 5 November 2015 the conclusion of “Accidental overdose of prescribed medication” was given.

Mrs Brookes-Walker had an extensive medical history dating back to her birth and for the last 4 years was using Fentanyl patches prescribed by her GP for relief of pain, which was severe. She was using one patch every 72 hours. Her uncle, ████████, who lived with her, gave evidence at the Inquest that he had applied a new patch to her shoulder the night before she died. He stated that he had difficulty removing it from its package and there had been previous like occasions when the patches would stick to the inside of the packaging, requiring force to remove them. The toxicologist giving evidence to the hearing, ████████, gave evidence that if this caused the patch to become damaged it was likely that an excessive amount of fentanyl was released into Ms Brookes-Walker's body. I concluded from the whole of the evidence that it was more likely than not that the patch had become inadvertently damaged whilst being removed from its packaging and this had led to a fatal amount of fentanyl being administered to Mrs Brookes-Walker. I stated in evidence that he was not aware of any danger arising from use of damaged patches and that he could not recall any warnings on the packaging regarding this. Furthermore, there had been occasions when all 5 patches contained within a single box were difficult to remove from their package, suggesting there may be a manufacturing fault in some batches.

Warning regarding the seriousness of the consequences of using damaged Fentanyl patches may not be apparent to the patient from the packaging