A WOMAN from Holyhead died after appearing to inadvertently overdose on her prescribed medication, an inquest heard.

Teresa Ann Bennett died at her home address aged 57 on December 1, 2021.

Following the conclusion of the inquest into her death on February 9, Sarah Riley, assistant coroner for North West Wales, has issued a Prevention of Future Deaths report.

This has been sent to Betsi Cadwaladr University Health Board, amid concerns about a lack of monitoring of patients’ medication reviews.

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The inquest had heard that Ms Bennett was taking 13 prescribed medications at the time of her death, seven of which had side effects linked to her central nervous system. 

On the evening of November 30, 2021, her son had seen her taking her medication as usual, before she retired to bed for the evening about 30 minutes later.

At roughly 3am on December 1, though, her son found her asleep on her bedroom floor, appearing to have fallen from her bed.

He helped her back to bed and left the room, but at about 12pm that day, he noticed she was still in bed, and it soon became apparent that she had died.

Ms Bennett’s medical cause of death was recorded as multi-organ failure, contributed to by fatty liver and combined drug toxicity.

A toxicology report showed that Fentanyl, one of her prescribed drugs, was within the toxic and fatal range at the time of her death.

She had been prescribed Fentanyl since 2008, with the instructions recorded in her GP notes stating: “remove old patch and apply new patch every 72 hours”.

The inquest heard no evidence to suggest that Ms Bennett was not compliant with taking her medication, nor that she had raised any concerns about it.

Her prescribed dose of Fentanyl, and her instructions for use, had not changed since 2008.

Ultimately, it appeared that Ms Bennett had applied a new Fentanyl patch without removing the old one, causing her to accidentally overdose on the drug.

It is standard health board practice for medication reviews to be completed at 12-to-15-month intervals but, in Ms Bennett’s case, this target had not been met since 2015.

In her report, Ms Riley wrote: “There is a lack of monitoring, and no standardised process, for medication reviews in the health board-managed practices.

“There is a risk of harm if medication reviews are not undertaken at regular intervals, including a risk of death in complex cases, like Ms Bennett’s.

“There is also a risk of harm or death if all pertinent matters are not considered during the reviews.

“At inquest, the health board produced an improvement plan that, inter alia, included actions to address the lack of compliance with the 12-to-15-monthly medication reviews.

“The target completion date for addressing the lack of compliance with the 12-to-15-monthly medication reviews is May 31, 2025, a further 15 months from now.

“This, in my view, is not quick enough, and I am concerned that future deaths may occur.”

Betsi Cadwaladr University Health Board is duty-bound to respond to the report by April 10.