Coroner's warning for GP practice after mum's tragic death

Bolton Coroner’s Court heard that Beverley Pennington known to her family as Bev, was found unresponsive at her Golborne home on August 1 last year.

Paramedics arrived but she was pronounced dead at the scene, aged just 58.

However, senior coroner for Manchester West Timothy Brennand said he was concerned that her GP surgery had not followed up a discharge letter from hospital saying her medication needed to be changed urgently enough.

Mr Brennand heard concerns from Beverley’s family that she was receiving too much of the powerful substances on prescription.

And a consultant at Wigan Infirmary, where Beverley had been taken about a week before her death, told the inquest that he had reduced her dose before discharging her home.

GP Dr Kevin Finn said he wished that he had spoken to the family more in what turned out to be the final stages of Beverley’s life.

Mr Brennand recorded a verdict of misadventure, saying Beverley had returned from the hospital keen to stick with the lower amount of medication doctors had suggested.

But he said it was likely that at some point just before her death she had tried to self-medicate for her pain, and was able to do so as the pharmacy had delivered two weeks’ worth of painkillers before she went into hospital.

The inquest heard the family hoped that lessons would be learned from the incident to prevent a repeat of the tragic circumstances that unfolded.

Mr Brennand said: “A letter of discharge doesn’t seem to have been brought to the attention of a GP and evaluated in such a way to make it clear that urgent action might well have been considered.

“I can’t say this would have had any bearing on the outcome even if it had been done, but it is a matter of practical concern.

“The family has expressed the wish that learning that can be shared and applied means that no other family and no other patient is put in a similar position.”

The inquest heard that Beverley had had a colourful life, running away to a circus aged 16 and working as a flamethrower.

In 1984, though, tragedy struck when there was a severe fire at her home and her eldest son died.

Beverley was pushed from the top floor of the property and broke her back, leading to a lifetime of spinal-related problems.

The inquest heard that in May 2020 Beverley had told her GP her back pain was increasing and extra morphine was added to her dosage.

Her daughter in law Stacey Cundliffe said that there were then two incidents in which family members phoned the emergency services as Beverley had fallen and was shaking and didn’t seem to understand what was happening around her.

She was admitted to Wigan Infirmary on July 24 and when consultant Hashim Hameed saw her on July 27 she was alert, able to answer questions and desperate to return to her Elm Avenue home.

Dr Hameed told the inquest he thought she was on a lot of morphine and he stopped the break-through pain relief medication, leaving her with tablets.

However, the oramorph he cut down had already been delivered to her home on July 21,

The GP surgery, though, did not identify this as a potential high risk and had instead arranged for blood tests to be done and for her medication to be reviewed the following week.

The family took it in turns to visit her at home after she was discharged from hospital and the inquest heard that on Friday July 31 everything was fine when one of her sons visited.

Earlier in the week, too, she had seemed positive and keen to follow the course of action suggested in hospital.

On the Saturday, though, there was no answer and when the family gained entry to the property Beverley was found collapsed and unresponsive.

Consultant pathologist Dr Emil Salmo said a toxicology report showed morphine in her system at a level that it could have proved fatal and lower levels of dihydrocodeine.

The post-mortem report also said she was more susceptible to the effects of toxicity due to suffering from COPD, pulmonary fibrosis and the thickening of the walls of her heart on the left-hand side.

Dr Finn said he now wished he had communicated more with Beverley’s relatives.

He said: “I wish I had spoken to the family directly. I wish had known that she was much clearer off the medication.

“I just wish there had been more time for us. We felt medication had been provided by the hospital and so the review didn’t need to be done immediately on the day of discharge.”

Mr Brennand extended his condolences to Beverley’s family.

He said: “Every time I say her name everyone in court smiles. She was clearly that kind of person.

“Beverley had an invaluable role as a sister, a mother and a grandmother. It’s important that you have those memories of her rather than the circumstances of her death to help you through the difficult phases of coming to terms with your loss, for which I am very sorry.”

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