Amanda Kramer
11 Sept 2023 · Coroner Graeme Irvine · East London
The coroner's concerns
1. dependency on Zoplicone
“Zoplicone is a drug licenced for the treatment of short-term insomnia. The risks associated with the drug are first, that it is a central nervous system depressant and second, that patients prescribed the drug can form a dependency upon it.”
2. long-term Zoplicone use
“Mrs [name redacted] was prescribed Zoplicone for 18 years.”
3. lack of medication review for high-risk patient
“Despite the deceased being under the care of both a GP and a secondary mental health trust prior to her death. No clear evidence emerged in this inquest that anyone had reviewed Mrs [name redacted] use of this drug even when Mrs [name redacted] had demonstrated a pattern of high-risk behaviour by deliberately overdosing on prescribed medication.”