Tammy Milward: Prevention of Future Deaths Report

Alcohol, drug and medication related deathsSuicide (from 2015)

Skip to related content

Date of report: 15/01/2025 

Ref: 2025-0027 

Deceased name: Tammy Milward 

Coroners name: Susan Ridge 

Coroners Area: Surrey 

Category: Alcohol, drug and medication related deaths | Suicide (from 2015)

This report is being sent to: Surrey and Borders Partnership NHS Foundation Trust | Esher Green Surgery 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS  
THIS REPORT IS BEING SENT TO:

[REDACTED}
Chief Executive  
Surrey and Borders Partnership NHS Foundation Trust
18 Mole Business Park   
Leatherhead   
Surrey KT22 7AD   

[REDACTED]
Esher Green Surgery
Esher Green Drive 
Esher 
Surrey 
KT10 8BX  
1CORONER 

Ms Susan Ridge, H.M. Assistant Coroner for Surrey
2CORONER’S LEGAL POWERS 

I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 
3INQUEST

An inquest into Ms Milward’s death was opened on 14 March 2024.  The inquest was resumed on 13 December 2024 and concluded on 20  December 2024.     

The medical cause of Ms Milward’s death was:
1a. Mixed Drug Toxicity

With respect to where, when and how Ms Milward came by her death it was recorded at Box 3 of the Record of Inquest as follows: 

Tammy Denise MILWARD was found unresponsive by police  following concerns for her welfare at her home in Esher Surrey on 1 January 2024. Her death was formally recorded by paramedics at  21:34 hours the same day. She had been prescribed [REDACTED] and toxicology revealed a potentially fatal concentration of [REDACTED], in  excess of prescribed levels, in her blood sample and that she had  also used cocaine shortly before her death. As a result, Ms Milward died of the effects of mixed drug toxicity.  

The inquest concluded with a short form conclusion of ‘Drug Related’:
4CIRCUMSTANCES OF THE DEATH

Ms Milward had a history of mental health problems including severe obsessive compulsive disorder. She was prescribed [REDACTED] and diazepam by her GP to help her deal with pain following a road traffic  collision in approximately 2012. She had become dependent on her  medication. On the advice of her GP, she wanted to reduce prescription  levels, but she found this difficult to achieve and on occasions Ms  Milward used her prescribed medication too quickly and had to request  more through her GP. This caused her distress, and she would self-harm, or threaten self-harm. Towards the latter part of 2023, the GP practice  referred Ms Milward to Surrey and Borders NHS Foundation Trust on  several occasions for mental health support. As a result advice was  provided by I-Access and she was referred to GP Integrated Mental  Health Service (GPimhs).  

On 28 December 2023, Ms Milward sent an email message asking to be  discharged from the GPimhs. In that email she accused her GPs of leaving her without medication and that “they are the reason for everything that  happens next”.  GPimhs did not contact Ms Milward about her message  and she was discharged from their service the next day. Separately on the  28 December 2023 Ms Milward’s pharmacy contacted her GP practice and told them she wanted her prescription and had threatened self-harm. The  practice spoke to Ms Milward and then the GP left a message for Ms  Milward confirming the prescription had been authorised and providing  her with crisis numbers.  The GP was unaware that GPimhs had received a message from Ms Milward and GPimhs was not aware of the welfare  concern raised by the pharmacy.   

Ms Milward phoned her mother in the early morning of 1 January 2024  and talked about going shopping. But later that day concerns were raised  about her wellbeing and police conducted a welfare check and found her  unresponsive. Toxicology revealed that she had used a significant amount of [REDACTED] as well as cocaine shortly before her death.   
5CORONER’S CONCERNS

The MATTERS OF CONCERN are:
The Inquest heard evidence that Ms Milward’s case presented treatment  challenges which several agencies sought to address but there was limited coordination, in particular that: 

a. The Coroner heard that the GP could not see GPimhs medical records  (or any SABP notes) which are recorded on SystmOne and that GPimhs could not easily access the GP medical records held on EMIS.  As a result, neither the GP practice, nor GPimhs was aware that the other had  received messages from or about Ms Milward on 28 December 2023. The  coroner heard from SABP that there is ongoing work ongoing to create  greater connectivity between the various electronic record systems, but  this work is not yet complete. 

b. The evidence heard suggests that there was little personal or practical  interaction between the GP practice and GPimhs. The coroner was told  that GPimhs had been recently introduced by SABP to work alongside GPs (addressing a need in primary care to provide mental health support)  but that levels of interaction varied and was sometimes also undermined  by a lack of suitable estate for co-location of GPimhs staff in GP practices. 
  
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.  
6ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I  believe that the people listed in paragraph one above have the power to take such action.   
7YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. 
Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must  explain why no action is proposed. 
8COPIES 

I have sent a copy of this report to the following:
1.  Chief Coroner  
2.  Ms Milward’s family  
3.  Surrey Adult Social Care  
4.  NHS Surrey Heartlands Integrated Care Board and Integrated Care System 
9Signed:
Susan Ridge 
H.M Assistant Coroner for Surrey
Dated this 15 day of January 2025