Amanda Kramer: Prevention of future deaths report

Hospital Death (Clinical Procedures and medical management) related deaths

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Date of report: 11/09/2023

Ref: 2023-0328

Deceased name: Amanda Kramer

Coroner name: Graeme Irvine

Coroner Area: East London

Category: Hospital Death (Clinical Procedures and medical management) related deaths

This report is being sent to: North East London Foundation Trust | Department of Health and Social Care | Wood Street Medical Centre

[REDACTED], North East London Foundation Trust (NELFT), CEME Centre, March Way, Rainham, Essex, RM13 8GQ [REDACTED]  
Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care, 39 Victoria St, Westminster, London SW1H 0EU    
[REDACTED], Wood Street Medical Centre, 6 Linford Road, Walthamstow, London, E17 3LA    
I am Graeme Irvine, senior coroner, for the coroner area of East London
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
htt p:// www ukpga/2009/25/schedule/ S/ paragra ph/7
htt p:/ / www.le gislat ion. uksi/ 2013/ 1629/ part / 7/ made
On 31st December 2022, this court commenced an investigation into the death of Amanda Jane Kramer aged 56 years. The investigation concluded at the end of the inquest on 15th August 2023. The court returned a narrative conclusion;  

“Mrs Amanda Jane Kramer died at her home address on 31st December 2022, she had taken an accidental, fatal overdose of Zoplicone. Mrs Kramer had been prescribed that medication for approximately 18 years, when guidance indicates it should be prescribed for the short-term treatment of insomnia. Those treating Mrs Kramer had not monitored; whether there was an ongoing need for her to receive this drug, the risks associated with the medication, or whether Mrs Kramer was compliant with dosage instructions.”
Mrs Kramer’s medical cause of death was determined as;
1.a. Zopiclone Toxicity
2. Fatty Liver Disease
Mrs Kramer was a 56-year-old female known to have suffered with depression since the 1990s. She received a diagnosis of schizoaffective disorder in 2009. Mrs Kramer also suffered with Arthritis and Fibromyalgia for which she was prescribed analgesia.
Mrs Kramer was noted to have had multiple emergency admissions to
hospital [REDACTED]

Mrs Kramer was found unresponsive at home on 31st December 2022. Her death was caused by an overdose of prescribed hypnotic, zoplicone.
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows.  
1.     Zoplicone is a drug licenced for the treatment of short-term insomnia. The risks associated with the drug are first, that it is a central nervous system depressant and second, that patients prescribed the drug can form a dependency upon it.
2.     Mrs Kramer was prescribed Zoplicone for 18 years.
3.     Despite the deceased being under the care of both a GP and a secondary mental health trust prior to her death. No clear evidence emerged in this inquest that anyone had reviewed Mrs Kramer’s use of this drug even when Mrs Kramer had demonstrated a pattern of high-risk behaviour by deliberately overdosing on prescribed medication.
In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by 6 November 2023 I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
I have sent a copy of my report to the Chief Coroner and the following, the family of Mrs Kramer. I have also sent it to local Director of Public Health who may find it useful or of interest.
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at he time of your response, about the release or the publication of your response.