A woman died after taking four times the prescribed amount of a very potent painkiller which is used to treat severe pain.
Keeks McClary, formerly known as Kerry Small, was found dead in her home in Pengegon, Camborne, by her sister on the afternoon of August 21 last year.
Kerry, 44, had long been suffering with chronic back pain, an inquest heard, and her prescription of the synthetic opioid fentanyl – which is similar to morphine but 50 to 100 times more potent – had been increased less than two weeks earlier.
Kerry was supposed to apply one fentanyl patch for 72 hours before replacing it, but at time of her death she was wearing four patches. A pathologist concluded that Kerry died as a result of fentanyl intoxication.
Kerry had a history of mental health problems and alcoholism, and had also previously made attempts on her own life. But her sister, Leah Willoughby, said Kerry was in a relatively positive frame of mind in her later years.
When coroner Guy Davies asked Leah if she believed Kerry had taken her own life, Leah replied, “absolutely not”.
Leah told the hearing: “The way she was in the last couple of years she was brilliant, she was a lot, lot better than she ever was.
“She was in a better place, she still obviously suffered but there was no intention to take her life. It was more pain relief than anything else [why she wore too many patches].”
Kerry and Leah visited a doctor together on August 7 to discuss Kerry’s weekly fentanyl patch, which was not potent enough to relieve her back pain for an entire week.
As a result Kerry had been applying two patches instead of one, despite having been warned previously to only wear one.
A GP, Dr Manisha Cooper, prescribed a stronger 72-hour patch, and again warned Kerry that she should not apply more than one patch at a time.
“She was not achieving pain relief [with the weekly patch],” said Dr Cooper. “With the 72-hour patch she would hopefully achieve better control, under the understanding that the directions would be complied with.”
Leah said that while neither she nor Kerry were told about the dangers of fentanyl, she did not blame the doctor for what had happened.
“The problem I have is it wasn’t explained how dangerous the drug was,” Leah said. “It was Kerry’s choice to put four patches on, she would have been aware she wasn’t allowed that many on. I don’t blame the doctor in any shape or form.”
Leah last saw her sister on August 15, and Kerry’s phone was last active three days later, the day it was suspected she had died. When a concerned Leah let herself into Kerry’s house at around 5pm on August 21, Kerry was unresponsive on the sofa. Leah said it was clear that Kerry had been dead for some time.
DC Rebecca Shorten, of Camborne CID, said Kerry was wearing more patches than she was prescribed to wear.
“She had apparently been doubling up on her old medication for some time. It is entirely possible that she believed she would be able to double up on these [stronger] patches just like she used to do,” said DC Shorten.
“There is nothing to suggest that Kerry wanted to end her life. It could well been an accident in that she thought she could double up on patches with the new medication, not realising the dangers.”
Coroner Mr Davies concluded that it was a drug related death. Kerry died from an overdose of prescribed drugs against a background of chronic back pain, he said.
“The evidence suggests Kerry had a history of taking powerful painkillers. Kerry was advised not to double up [on her medication].
“Kerry was doubling up on painkillers so it was central issue for discussion on the 7th of August [with the doctor]. I accept that a further warning will have been issued on the 7th of August because it is a usual practice to warn of the risks. There has been no neglect in this case.
“Did Kerry intend to take her own life? I find not.”
Kerry’s sister Leah has urged doctors to strongly reiterate to patients the dangers potent painkillers such as fentanyl pose.
“Kerry although very troubled had lots of love to give, she had an amazing sense of humour and was extremely creative,” said Leah after the inquest hearing.
“She is sorely missed by everybody who knew her we all love and miss her dearly. We hope by Kerry’s accident being reported it will help people become more aware of the dangers and for doctors to educate their patients on the serious risks of the drug.”