Lowestoft mother died from overdose after morphine prescription

Karen Lee who died in her flat in Lowestoft on New Year's Day 2015. Photo: Submitted

Karen Lee who died in her flat in Lowestoft on New Year's Day 2015. Photo: Submitted - Credit: Submitted

A coroner has said 'the system did not work properly' after a mother died from a morphine overdose in her flat, after being prescribed the drug following an operation.

Karen Lee, 51, of Lyndhurst Road, Lowestoft, received a knee replacement at the James Paget University Hospital (JPH), in Gorleston, in December 2014.

At the end of a three-day inquest, Greater Suffolk coroner Dr Peter Dean recorded a narrative conclusion, stating that Mrs Lee died from the excessive consumption of prescribed medication, and added: 'Whether this was intentional or accidental is not clear from the evidence.'

The mother-of-three was admitted to the JPH on December 9 suffering from severe pain.

She badly damaged her knee in a horse-riding accident in 1998 and over the years began using morphine-based drugs to ease her pain.

Mrs Lee had been admitted to hospital in the past for overdosing on alcohol and prescription medication.

On December 19 while in hospital, an orthopaedic ward sister thought Mrs Lee might be suffering from bi-polar disorder and arranged for a mental-health assessment.

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A response was expected within 72 hours; however, the wrong form was used and it was not until December 23 when another nurse called the referral service that the error was spotted.

On December 30 a nurse with mental-health training saw Mrs Lee, the day of her discharge.

When she was discharged she was given three days' worth of the drug Oramorph to take home with her.

The amount was limited as staff were concerned she was showing 'drug-seeking' behaviour as this was the only drug she said eased her pain.

On December 31 Mrs Lee contacted her GP as she was concerned she would run out of pain relief as the following day was a bank holiday.

Given her limited mobility and anxiety about running out, her GP prescribed her two weeks' worth of Oramorph – still a limited amount as controlled medicines are usually prescribed for a month.

He did not, however, receive a copy of her discharge paper from the hospital until January 2, 2015, a day after she died.

Dr Dean said there was 'No suggestion that anyone in their position as a health care professional did anything other than act in good faith to try to assist Karen, but clearly the system did not work properly.'

Dr Dean made three recommendations to prevent future deaths:

• A combined approach of physical health care providers and mental health care providers working together.

• If a mental health referral is sent to the wrong place or person, it should be the responsibility of the person who receives it to make sure it gets to the correct place or person.

• Before a patient is discharged, an electronic copy of their discharge form should be sent to the GP, as well as the paper copy that is given to the patient. At present the GP usually receives an electronic copy within 24 hours subject to admin staff being available.


Anna Hills, director of governance for the James Paget University Hospital, said: 'Our sympathies remain with Mrs Lee's family, following her death in January 2015.

'Prior to the inquest taking place, we carried out a full investigation into the care provided to Mrs Lee while she was at the hospital.

'As a result of this, we identified changes to strengthen some of our documentation procedures relating to patient discharge. These have already been implemented. In line with the comments made by the coroner at the inquest, we will be working with our colleagues at the Norfolk and Suffolk NHS Foundation Trust to improve communication between our organisations – and have already carried out training with key staff to reinforce their knowledge of the referrals process. Our priority is safe patient care – and we always aim to put our patients first, with a commitment to continuous improvement and, where appropriate, implementing learning.'

Jane Sayer, director of nursing, quality and patient safety at the Norfolk and Suffolk Foundation Trust, said: 'We would like to offer our most sincere condolences to Mrs Lee's family and friends. We acknowledge the findings of the coroner and we will be working closely with the James Paget Hospital to improve the referral process and communication between our trusts.'