Published at 09:16, Friday, 20 July 2012

A mum who was allowed to leave hospital without her GP being told died after she inadvertently overdosed on pain killers.

Becky Jackson

The coroner investigating the death of 31-year-old Becky Jackson now plans to write to the boss of north Cumbria’s two main hospitals in the hope of preventing any possible repeat of the tragedy.

An inquest heard the mother of three young children had been in severe pain because of a condition affecting her pancreas gland.

Mrs Jackson - described by her family as bubbly, amazing and devoted to her family - discharged herself from The Cumberland Infirmary, Carlisle, on December 15, 2010, because she was unhappy with her care and felt that she would be better off at her home in Beverley Rise, Harraby.

At the time, North Cumbria University Hospitals NHS Trust, which runs both the Infirmary and the West Cumberland Hospital in Whitehaven, had a policy stipulating staff should contact the family doctor of any patient who self-discharges.

But in Mrs Jackson’s case, there was no evidence that this ever happened, an inquest heard.

A senior nurse who testified at the inquest confirmed she was unaware that she was meant to contact the patient’s GP in such cases.

Sixteen days after she left hospital, on December 31, Mrs Jackson’s condition deteriorated and despite attempts to revive her she died.

Pathology tests showed her death was caused by the combined effects of pneumonia and “toxic levels” of the pain killers co-codamol and paracetamol.

The inquest heard Mrs Jackson, whose children are aged two, five and 10, had a history of lower back pain, for which her GP prescribed co-codamol. She had also suffered from depression but this was successfully treated by her doctor.

On June 20, 2010, shortly after being treated for a chest infection, she was admitted to the infirmary suffering from abdominal pain. Doctors diagnosed gall stones and her gall bladder was removed.

On December 8, she was readmitted to hospital with severe abdominal pain and this time medics diagnosed an inflammation of her pancreas, a gland producing insulin and enzymes to aid digestion.

She was initially treated with intravenous pain killers but by December 14 doctors felt it wise to move her on to orally administered pain killers. Mrs Jackson had wanted to go back on to intravenous pain relief but this was refused.

On December 15, as medics were working towards the right regime of pain killers, Mrs Jackson decided to discharge herself.

“She probably would have been discharged on December 16,” said Simon Raimes, the consultant general surgeon treating her.

Medical notes showed that nursing staff advised Mrs Jackson not to leave the hospital and Mr Raimes said he was not aware of any attempt to contact her GP – something specifically requested by the trust’s discharge policy in such circumstances.

Sister Victoria Sewell confirmed that she was unaware at that time of the need to contact the GP of a patient who has self-discharged but added that the policy has now been “fully implemented” in the ward concerned.

Mrs Jackson’s husband David, an archaeologist, said his wife was “pretty good” at controlling her medication.

He added his wife would never have intentionally left her family behind and would not have even considered it. Despite him encouraging her to seek medical help, she feared a readmission to hospital and refused, he said.

He said she was in pain, sleeping intermittently, and may have taken more pills than she intended.

North and west Cumbria coroner David Roberts recorded a misadventure verdict – meaning Mrs Jackson’s death was the unintended consequence of her actions. She took excessive quantities of medication while in pain and not thinking clearly.

Mr Roberts said he would write to the trust’s chief executive in the hope of preventing any possible future deaths as a result of similar circumstances. He said his letter would focus on the trust's discharge policy, and added: “It’s understandably a matter of concern to me that nursing staff on this ward and presumably elsewhere were not aware of the policy, and in particular the discharge form."

He said he would urge the trust to ensure staff are aware of and follow the policy, in particular the need to contact a patient’s GP. In Mrs Jackson’s case, such contact may have prompted her GP to give her further treatment, he said.

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