KATHRYN LOUISE SAWYER · Prevention of Future Deaths report

On 15th August 2013 I commenced an investigation into the death of KATHRYN LOUISE SAWYER, 33 years. The investigation concluded at the end of the inquest on 8th APRIL 2014. The medical cause of death was Respiratory failure due to overdose of Methadone in combination with therapeutic levels of other drugs. The conclusion of the inquest was Accidental overdose of prescribed medication.

Mrs Sawyer had a significant history of mental health issues. She was prescribed Chloral Betaine in 2003. She was prescribed Methadone in 2011 following an addiction to Codeine. Mrs Sawyer was seen regularly at her GP surgery and by Mental Health Services. At the time of her death Mrs Sawyer was prescribed a number of different medications. Mrs Sawyer was very knowledgeable about medication and regularly requested increases. On 14th August 2013 Mrs Sawyer was found collapsed and unresponsive at the bottom of a flight of stairs in the communal hallway at her home address. She was found by a neighbour who called the ambulance service. Mrs Sawyer was transferred to Norfolk & Norwich University Hospital where she died shortly after arrival.

(1) Mrs Sawyer registered with the Roundwell Surgery in July 2012 at which time she was known to be addicted to Chloral Betaine (she was prescribed double the dosage recommended in the BNF) and was prescribed a number of different additional medications, including Methadone (prescribed by Trust Alcohol and Drug Service);

(2) She attended the Surgery with a letter from her previous GP expressing Mrs Sawyers' concerns about her medication being decreased. It was felt sensible to allow her to feel comfortable with the Surgery before consideration was given to the medication and amounts she was being prescribed. This is accepted as reasonable.
(3) During the course of the next 13 months Mrs Sawyer was seen by the Practice on a regular basis when her medication was varied and/or increased. She was admitted to Hospital in November 2012 as a result of an overdose.
(4) Mrs Sawyer’s mental health condition stabilised in Spring 2013 when she attended the Surgery for physical problems only.
(5) Her medication was not reviewed by the Surgery until June 2013. It was then reviewed by a Locum Doctor. There is no or no detailed record of the discussion relating to her medication and no plan made between patient and the surgery with regard to future medication and in particular any plan to decrease.