Joy Ebanks: Prevention of future deaths report

Alcohol, drug and medication related deaths

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Date of report: 02/01/2024

Ref: 2024-0002

Deceased name: Joy Ebanks

Coroner name: Sean Cummings

Coroner Area: Bedfordshire and Luton

Category: Alcohol, drug and medication related deaths

This report is being sent to: Kirby Road Surgery

2    Kirby Road Surgery
I am Sean CUMMINGS, Assistant Coroner for the coroner area of Bedfordshire and Luton Coroner Service
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.
On 14 June 2023 I commenced an investigation into the death of Joy EBANKS aged 59. The investigation concluded at the end of the inquest on 13 December 2023. The conclusion of the inquest was that:  

Mrs Joy Ebanks was discovered deceased on the 24th May 2023 at [REDACTED] . She was taking oxycodone and pregabalin as treatment for pain. The medical cause of death was identified as due to oxycodone and pregabalin toxicity.
Mrs Ebanks lived alone, she had been self neglecting and not engaging with support services. She suffered from Fibromyalgia, arthritis, agoraphobia. She had been diagnosed with depression and was prescribed both venlafaxine and quetiapine. She used cannabis.

On the 24/05/2023, Mrs Ebanks was spoken to on the phone by her care worker at around 12:00 hours and asked for some tobacco to be bought to her during the visit. At around 16:00 hours, her care worker attended, got no response and so let herself in. She found Mrs Ebanks unresponsive, sitting up slumped to the side on the bed and contacted ambulance before attempting CPR. Paramedics attended but were unable to resuscitate her and she was pronounced deceased at the scene. There were previous expressions of suicide but she had not acted on them.  

Post mortem examination with toxicology gave the medical cause of death as:
1a Oxycodone toxicity enhanced by pregabalin intake
11 Bronchopneumonia, Coronary arteries atherosclerosis, Hepatic steatosis  

Mrs Ebanks had been prescribed opiates since at least 2009. Her medications at the time of death included long acting morphine – Longtec [REDACTED] twice daily together with Pregabalin [REDACTED] twice daily. She had been on this dose since at least 2014. There were periodic supplementations with Shortec [REDACTED] 1-2 tablets up to four times daily (112 provided). The reason for the prescription was for fibromyalgia and “chronic pain” (undefined). Because of her agoraphobia and a dislike of people coming to her home, medication reviews were undertaken largely by telephone. There was evidence of poor communications between the agencies providing her with different aspects of her care.

I was told that the practice had been addressing Prescription Drug Dependency and had utilised the Quality and Outcomes Framework Guidance for 2022/2023. Page 5 “Prescription Drug Dependency – Rationale” sets out some reasons for monitoring and rationalising prescription of dependency forming drugs thus:
“Opioids are very valuable drugs for acute and palliative/end of life care but have a limited role in the management of chronic pain; for many patients they are not effective. Most prescribing is of short duration only; however, 3% of patients (CQC, 20202) with chronic pain receive continuing prescriptions for opioids for 3 years or more. Prolonged prescribing of these drugs may not be effective and is associated with dependence.
Gabapentinoid prescribing has shown a 10 fold increase between 2000 and 2015 from 0.2% of patients in 2000 to 2.1% in 2015 (Cartagena et al. 2017),most of which has been off label and of unknown effectiveness; dependence on these drugs is increasingly recognised as a problem”.
There was evidence of attempts to review the medication prescribed but I remained unclear as to the purpose of the reviews. There was no evidence of any attempt to review the prescriptions of two dependency forming drugs with a view to reducing the dose over time. The opioid prescription was high. Mrs Ebanks was an agoraphobic lady with an ongoing mental health illness and what appears to be a iatrogenic drug dependency.
During the course of the investigation my inquiries 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:
(brief summary of matters of concern)
1) There was evidence of very prolonged prescribing of two dependency forming drugs with no evidence to suggest that a discussion had been had or plan had been formulated to reduce the dosages.
2) The Guidance for Prescription Drug Dependency used by the practice highlights the hazards and limited utility of long term prescription of opioids for chronic pain. It also highlights the poor evidence base for use of gabapentinoids in these circumstances.
3) The primary cause of death was 1a Oxycodone toxicity enhanced by pregabalin intake.
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 February 27, 2024. 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 to the following Interested Persons:- Ms Ebanks NOK
I have also sent it to :- East London NHS Foundation Trust
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 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 the time of your response about the release or the publication of your response by the Chief Coroner.
9Dated: 02/01/2024
Assistant Coroner for Bedfordshire and Luton Coroner Service