Coroner Nicholas Walker last week (March 7) raised concerns that a drug interaction does “not trigger an alert on the prescribing software used in primary care or by pharmacists” after a patient suffered sudden cardiac death.
Walker’s report found that Chloe Burgess “was prescribed heart medication after a diagnosis of sinus tachycardia and left bundle branch block as well as antidepressant medication”.
“It is likely that the medications interacted with each other to raise the levels of amitriptyline in [her] blood,” he said.
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He added that this, “combined with her heart medication and an episode of sleep apnoea, induced severe cardiac arrhythmia and sudden cardiac death” before she was found deceased at her home in Southampton on September 8 2023.
“She had been using the combination of drugs for four years before she died without concern,” he said.
“The potential dangers of the combination of drugs in [Burgess’] case was not well-known or appreciated by those treating her,” he added.
“Prevent future deaths”
Walker said that it was a “matter of concern” that “the combination of amitriptyline, paroxetine and ivabradine…[did] not trigger an alert on the prescribing software used in primary care or by pharmacists”.
“The potential dangers related to a failure to metabolise amitriptyline that can, incrementally, lead to toxicity,” he added.
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“I am also concerned that those prescribing ivabradine should have a full understanding of the potential interaction with amitriptyline and paroxetine,” he said.
Walker sent a copy of his report to the National Institute for Health and Care Excellence (NICE) and the British National Formulary (BNF), as well as the Royal College of Physicians, saying that the bodies “have the power” to “prevent future deaths”.
C+D approached the bodies for comment.
“Mixed drug toxicity”
In January, a coroner warned that the lack of “communication between primary and secondary care” may lead to the “early death” of more patients.
She made the comment after a patient died of “mixed drug toxicity”, despite multiple warning messages that were sent to her GP and NHS trust.
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Meanwhile, a GP warned in January that pharmacies “need” to review patient records before prescribing, during the inquest of a patient who died after obtaining drugs through an online pharmacy.
“The process required to do this was described as a ‘tick-box’ exercise in court,” coroner Nigel Parsley added.
