Lyndsey Holt · Prevention of Future Deaths report

On 11/04/2016 I commenced an investigation into the death of Lyndsey Holt, 36 . The investigation concluded at the end of the inquest on 29 March 2017. The conclusion of the inquest was Natural Causes. The cause of death was 1a. Shock and haemorrhage due to 1b. Perforated Gastric Ulcer.

Miss Holt was 37 weeks pregnant with her third child. There had been no complications during that pregnancy save that she had suffered from severe and painful varicose veins. In 2011 Miss Holt had been prescribed with methadone following a telephone conversation with the prescribing GP who considered that her reported history included reference to there having been a lengthy dependence on Codeine and also that she had taken Oxycodone and Tramadol. Specific details of the frequency of usage and amount taken could not be provided to the court. The dose of methadone had been significantly reduced during Miss Holt’s second and third pregnancies. It appeared that as well as methadone, Miss Holt took paracetamol for pain relief of the varicose veins and, when particularly severe, took her partner’s Oxycodone medication. On the 2nd April 2016 Miss Holt collapsed at 18:55 due to a gastric ulcer having perforated and there being catastrophic bleeding thereafter. She was conveyed by ambulance to the Rotherham Hospital. On leaving the address a pre-alert was requested from the ambulance crew via Control but Control failed to pass the pre-alert onto the receiving hospital. Had they done so clinicians at Rotherham would have been aware of Miss Holt’s impending arrival, likely timing of arrival and the seriousness of the situation they were about to face. Once Miss Holt arrived at the A&E Department of the Rotherham Hospital an emergency caesarean section was rapidly performed, extensive resuscitation measures put in place, she underwent a splenectomy, repair of a ruptured gastric ulcer and towards the end of her life a hysterectomy in a last ditch effort to try and save her. The overwhelming coagulopathy she had developed and shutting down of organs led to her death on the morning of the 3rd April 2016 from shock and haemorrhage due to a perforated gastric ulcer.

The circumstances in which the methadone was prescribed namely:
(1) Doing so over the telephone with no face to face consultation.
(2) Consequent lack of detail regarding:
2.1 the drugs being taken by Miss Holt
2.2 the frequency with which they were being taken
2.3 the degree if any, of her dependence
2.4 absence of assessment of any psychological issues
(3) Providing a methadone naïve patient with a 7 day supply.
(4) Lack of medical review during the initial phase.