Tragic death was due to medicines
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A‘FABULOUS’ Widnes mum who suffered a tragic decline in health died after taking a combination of prescription drugs and a potent opioid medicine she obtained by other means.
An inquest at Warrington Coroner’s Court last Thursday heard that Tracey Ann Edwards, 40, of Saxon Terrace, was found dead on the bathroom floor by her daughter’s boyfriend Ben Cetton in the early hours of May 27 last year.
Paramedics attended but were unable to save her.
Family members at the inquest raised issues about aspects of her care, namely that although health services had tried to help Tracy as individual services, it was claimed there was a lack of coordination or communication.
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Valerie Armor, sister of the deceased, spoke to confirm details of Tracy’s medical history and expressed concern that alternatives to painkillers were not used more to deal with Tracy’s chronic pain problems, and ‘especially because of her mental health’.
She said: “I was concerned about the amount of different people she was seeing. The response was always medical.
“It was always medication.”
Mrs Armor told the hearing that Tracy’s life had been very different before she became ill in 2011.
She said: “I’d just like to say, previous to 2011 Tracy lived a great life.
“She’s the youngest of six siblings, she was a baby and spoiled, she was very privileged, she was very happy and had a wonderful daughter.”
She added: “She was a fabulous mother before some of her issues began.”
Tracy’s health deteriorated from 2011 and she underwent brain and spinal surgery.
She developed further symptoms including leg swelling and chronic pain and was prescribed a variety of medicine.
Her mobility was also reduced.
Toxicology tests conducted by forensic toxicologist Dawn Reed found the following substances in Tracy’s system: oxycodone, quetiapine, amitriptyline, pregabalin, diazepam, paracetamol, and methadone.
The toxicologist said the amount of oxycodone – a powerful opioid painkiller – would depend on Tracy’s level of tolerance.
Although most were prescription drugs, Tracy had not been prescribed methadone, which is usually a heroin substitute opioid medication but can also be used as a painkiller.
There was no suggestion that Tracy had been using illicit drugs, but a half-empty methadone bottle with the label scratched off was found at her home following her death.
The label would have shown who the bottle had been prescribed to.
Mrs Reed said the effects of the various drugs may have been ‘additive’.
A post-mortem examination by Dr Jasna Krajacevic concluded ‘that the enhanced toxic effects of multiple drugs most likely caused depression of the central nervous system’ and was the cause of death.
Dr Christopher Findlay, consultant psychiatrist, discussed Tracy’s care and said her medicines were prescribed at low doses.
He added that he provided updates Tracy’s general practitioner (GP) on her treatment.
Dr Michael McLaughlin, of Peelhouse Medical Plaza, told the inquest Tracy had a ‘complex’ medical history and that the ‘combination’ of issues made ‘helping Tracy more difficult’.
He discussed the challenges of managing opioid medications, telling the hearing that she had managed to stop taking the liquid form of morphine ‘Oramorph’ in 2014, which had initially been prescribed while she in accident and emergency, and although ‘her opioid burden was significantly reduced later, she was never able to get off them, she still had the pain problems’, particularly as she had further brain surgery in 2018. He said: “I think it’s fair both myself and Tracy were very keen to reduce her medication but she wasn’t able to do it because of the pain she was in.”
‘Drug-seeking issues’ developed and she began asking for earlier prescriptions ‘a day or two early’ and he noted in her records ‘we need to be careful’.
Dr McLaughlin saw her on May 20 and he declined a request for an early opioid prescription.
He also prescribed the non-opioid painkiller nefopam.
The GP said there was more communication behind the scenes about Tracy’s treatment than might have been apparent.
Asked by Peter Sigee, assistant coroner for Cheshire, if he had a good understanding of the healthcare being provided by various professionals to Tracy, he said ‘definitely’.
Dr McLaughlin said there was a gap in the health services for providing rehabilitation and recovery for patients with opioid medication dependance, but had Tracy been willing to see the drink and drug recovery service Change Grow Live, she would have been able to access that type of support.
Mr Sigee cited a statement from Dr McLaughlin that said ‘the practice and he personally took Tracy’s health and pain very seriously’ and she had regular appointments and home visits.
He said he was ‘saddened’ that Tracy’s family thought staff had been ‘rude’ to Tracy and that ‘that was certainly not their intention’ and not his ‘experience of the care she received’.
Earlier in the inquest, Mrs Armor had expressed concern after Tracy had told her that a practice employee had said ‘oh no, not Tracy again’ when she attended on one occasion.
The inquest heard from Carla Nightingale, of North West Boroughs NHS Healthcare Trust, who investigated Tracy’s involvement with the trust and reported there were ‘issues’ with regards to monitoring Tracy’s lithium intake.
Having reviewed the evidence, from 13 witnesses, Mr Sigee concluded that Tracy Ann Edwards died due to the ‘enhanced toxicity of multiple drugs’ and her death was drug-related.
He concluded that although it was ‘recognised that communication could have been more effective’ and there had been ‘some lack of coordination’ between health services, he said this did not amount to a failure in basic service or neglect.
Tracy Ann Edwards was born in Whiston in 1978 and worked as a carer.