Coroner Susan Ridge last week (January 15) wrote a report to prevent “future deaths” after patient Tammy Milward died of “mixed drug toxicity”, despite multiple warning messages that were sent to Milward’s GP and NHS trust.
The assistant coroner for Surrey said that Milward was prescribed medicines including diazepam by her GP “to help her deal with pain following a road traffic collision in approximately 2012” and “had become dependent on her medication”.
Read more: Coroner: Patient died from overdose after GP pharmacist ignored warning
Ridge added that Milward, who “had a history of mental health problems including severe obsessive compulsive disorder (OCD)”, “wanted to reduce prescription levels” on the advice of her GP.
But Milward found this “difficult” and sometimes took her medication “too quickly and had to request more”, which “caused her distress and she would self-harm or threaten self-harm”, Ridge said.
“Not aware”
In 2023, Milward was referred to the GP integrated mental health service (GPimhs) through Surrey and Borders NHS Foundation Trust, Ridge said.
Her report added that on December 28 2023, Milward sent an email asking to be discharged from the GPimhs and accusing her GPs of “leaving her without medication”, adding that “they are the reason for everything that happens next”.
That day, Milward’s pharmacy separately contacted her GP practice and told them she wanted her prescription and had threatened self-harm – the practice authorised the prescription and provided crisis numbers for Milward, the report said.
Read more: Coroner: Man dies by suicide after GP deregistration despite pharmacy plea
“The GP was unaware that GPimhs had received a message from Milward and GPimhs was not aware of the welfare concern raised by the pharmacy,” Ridge stressed.
On January 1 2024, Milward “was found unresponsive by police following concerns for her welfare at her home in Esher Surrey”, the report said.
Toxicology revealed a “potentially fatal concentration” of medication “in excess of prescribed levels in her blood sample and that she had also used cocaine shortly before her death”, it added.
“Lack of coordination and communication”
Ridge‘s report found that Milward’s case “presented treatment challenges that several agencies sought to address – but there was limited coordination”.
“The evidence heard suggests that there was little personal or practical interaction between the GP practice and GPimhs,” she added.
“The coroner is concerned that the lack of coordination and communication between primary and secondary care providers may place patients at risk of early death,” she said.
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She also expressed concerns that “the GP could not see GPimhs medical records…which are recorded on SystmOne and that GPimhs could not easily access the GP medical records held on EMIS”.
C+D approached Milward’s GP practice for comment.
“A national issue”
Chief executive of Surrey and Borders Partnership NHS Foundation Trust Graham Wareham yesterday (January 20) told C+D that the trust is “deeply saddened by the tragic death of Tammy Milward and [its] deepest condolences go to her family”.
“While the coroner did not find that the care provided by Surrey and Borders Partnership contributed to [her] death, we do recognise the coroner’s finding that there is a need to improve communication and coordination between different healthcare providers,” he added.
“This is a national issue that we take very seriously,” he said.
Read more: Patient dies after pharmacy ‘unable to supply’ epilepsy meds for 10 days
“We are supporting the national GP Connect programme due to launch in the first half of this year that will enable improved live data-sharing from GP practices,” he added.
Meanwhile in June, a coroner raised concerns about GP practice “safety measures” after advice from a dispensing pharmacist and consultant psychiatrist was ignored.
The following month, a coroner also wrote to a GP surgery after it ignored multiple emails sent by a pharmacy “to seek authorisation” for a patient’s anti-psychotic medication before he died by suicide.
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