Irene Anne Pearson · Prevention of Future Deaths report

On 15th October 2015 I commenced an investigation into the death of Irene Anne Pearson dob 12th July 1941. The investigation concluded on the 18th January 2016 and the conclusion was one of Misadventure. The medical cause of death was 1a Opiate Toxicity .11 Carcinosis, Carcinoma Colon and Ischaemic Heart disease.

The deceased was diagnosed with terminal cancer of the colon which had then spread to various other organs (carcinosis). As part of her palliative care, she was prescribed Matrifen patches. She was ill-advised as to the level of medication which she needed and as to the precise effects of certain actions upon the delivery of such. On the 19th July 2015, at her home, she had a hot bath and was found dead in the bath, with the hot tap running. It is believed she was wearing the patch when she got into the bath.

1. The package leaflet of advice on the use of Matrifen is very extensive running to several pages of closely printed words. It is not until half way down the eighth page (and then contained in the middle of a 4th bullet point) that there is reference to the danger of taking a hot bath whilst wearing the patch. The Forensic Consultant Toxicologist gave evidence to me that heating of the body will cause an onrush of the delivery of the drug. (Takeda UK)

2. Even when the said warning phrase is reached in the leaflet, it then refers to “a prolonged hot bath” without in any way defining the words “prolonged” or “hot”. These terms are easily open to subjective interpretation, which may lead to an unsafe usage environment. (Takeda UK)

3. I heard evidence that the Macmillan Nurses had advised the deceased to take a bath when preparing to remove the ‘exhausted’ patch so as to aid removal. The toxicologist point out that even when due for changing the patch contains (and therefore can release) a very considerable level of the drug. The advice to use this method of removal would therefore be inherently potentially dangerous.(Macmillan Cancer Care)

4. I was told that the Macmillan Nurses will prescribe additional opiate pain-control, but there seemed little or no liaison with the GP Practice as to the regulation of this.(Macmillan Cancer Care)

5. The GP Practice’s electronic notes of the attendances upon the patient were unclear and there appeared to be discrepancies between what was noted as prescribed by way of opiate patches, and what the patient actually had in her possession. The notes were on occasions ‘scanty’ in detail and the doctor giving evidence accepted this and told me that this was because they, as doctors, are limited to ten-minute appointments and they do not always have time properly to record their notes. (Churchgate Surgery)

6. When HM Coroner asks for a full report of the care of the patient from the General Practitioner, it is insufficient (as in this case), for the practice simply to photocopy part of the patient’s records. (Churchgate Surgery)