Ilford mother 'could have been saved' and NHS 'failed' her, family tells inquest

Walthamstow Coroner's Court

Coroner Graeme Irvine, based at Walthamstow Coroner's Court (pictured) has sent a prevention of future deaths report to Newbury Group Practice after an inquest into the death of Ilford mother Anita Mandalia. - Credit: Google

The family of an Ilford mother who died after accidentally overdosing on her medication told an inquest that she was "failed" by the NHS and could have been saved.

Anita Mandalia, 58, died in hospital on February 11 after taking an unknown quantity of her medications, which included psychiatric drugs, sleeping pills and prescription painkillers.

An inquest last week heard Newbury Group Practice did not review her medication, despite concerns about her overdose risk, and prescribed a sleeping pill far longer than recommended. 

Following her discharge from mental health services run by North East London NHS Foundation Trust (NELFT) last August, it also failed to re-refer her when the family raised new concerns.

In a report published on Friday, July 9, coroner Graeme Irvine said there was “a risk future deaths could occur unless action is taken” at the practice.

In a statement read out at the inquest, Anita’s family said their concerns about her “were not taken seriously” despite a “constant battle” to explain the danger she faced.

The statement read: “My mother has now become a statistic but she could have been saved. At no time were attempts made to reduce her medication or offer to have a review.

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“The NHS have failed in their duty of care and have a blatant disregard for the family’s concerns. My mother’s difficulties were constantly overlooked and we feel nothing substantial was done.”

The family claimed that Anita was treated "like a guinea pig" with the medications she was on.

The court heard from Dr Fitzroy Clarke, practice manager, that at the time of her death Anita had been prescribed her sleeping pill, which he admitted was “meant for short-term use”, since June 2019.

Dr Irvine noted this was well outside the timeframe recommended by the National Institute for Health and Care Excellence, specifically due to the drug’s risk of tolerance and addiction.

He told Dr Clarke: “As a GP, one of your roles is to try to ensure that somebody has a comprehensive view of each patient’s holistic care when there are multiple doctors involved.

“Things were trundling along with nobody noticing she had been on this medication for so long, it’s of little significance to me that she did not appear to have signs of addiction.

“My concern is that nobody ever sat and thought critically about the list of medications Mrs Mandalia was on.”

In June last year, Dr Clarke said that, in response to concerns about Anita, the GP began issuing only a week’s supply of her medication at a time.

Dr Irvine questioned why there was no review of her medication after this decision and why she was given a full prescription for a “very powerful” painkiller in January.

He also pointed out that, on two occasions following Anita’s discharge from NELFT, her daughter rang the surgery to express concerns and was told to “speak to the psychiatric team”.

He said: “That advice was not proper because at the time there was no psychiatric team [working with her]. It was the responsibility of the GP to make a further referral.”

A spokesperson for NHS North East London Clinical Commissioning Group on behalf of the practice said: “We would like to express our sincere condolences to the family of Mrs Mandalia at this very difficult time.

"We are taking this incident extremely seriously and will absolutely continue to take on board any recommendations and ensure that the lessons learned inform the way we interact with our patients going forward.”

The practice has until September 2 to respond to the coroner’s report, although Dr Clarke told the court that all concerns would be taken on board.

The inquest found that Anita’s death was an accident.

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