UK Inquiry Tracker

Denise Parramore

PFD Report Historic (No Identified Response) Ref: 2014-0247

Date of Report 19 May 2014

Coroner Donald Coutts-Wood

Coroner Area South Yorkshire (West)

Response Deadline ✓ from report 11 August 2014

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

A lack of open, two-way communication and inability to access shared documentation between primary and secondary care meant psychiatric services were unaware of critical medication prescriptions.

View full coroner's concerns

In the circumstances it is my statutory duty t0 report to you_ _ (1) The Psychiatric Services, and in particular her Consultant Psychiatrist; was not aware, prior to Denise Parramore's death, of her being prescribed Tramadol by her General Practitioner. Concerns would have been raised, and action likely taken; if she had been aware_ The Consultant Psychiatrist was not informed either by Mrs Parramore herself; nor the General Practitioner of the prescribing of the Tramadol: My concern is that there should be open, and constant two-way communication between those in primary care and secondary care such as in these circumstances_ (2) For the same reasons as given above, will it be possible for those in primary and secondary care access each other' s documentation, which would likely have revealed the prescribing:

Sent To

NHS England
NHS Sheffield Clinical Commissioning Group

Response Status

Linked responses 0 of 2

56-Day Deadline 11 Aug 2014

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On the 20th February 2012 commenced an investigation into the death of Denise Sharon Parramore, who was born on the 19th December 1958. The investigation concluded at the end of the inquest on the 1g/h November 2013_ The conclusion of the inquest was that Ms Parramore died on the 19th February 2012 a Bradfield, Sheffield to respiratory depression as a result of acute administration of Tramadol in excess of the level prescribed taken in the prior to her death in combination with Benzodiazepines, Venlafaxine and Pregabalin. due day

Circumstances of the Death

Denise Sharon Parramore had a lengthy history of mental ill health She was first under the care of Psychiatric Services in Sheffield in 1999_ In the ensuing years there were a number of serious incidents of self-harm , and repeated indications of suicidal thoughts_ On the 13th December 201 Denise Parramore took an overdose of prescribed medication She was subsequently discharged by the relevant psychiatric team in January 2012 when it is understood her medication included Pregabalin; Venlafaxine and Benzodiazepines_ She was due to have a further appointment with the home treatment team at the end of February 2012. Denise Parramore's General Practitioner had been prescribing Tramadol since September 2010, for chronic pain. Denise Parramore was found deceased on the 20th February 2012.

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. Is there an intention for a National scoring system to be introduced, and indeed is consideration being given to the introduction of computerised systems that lead to automatic referral to the relevant senior doctor?