Louise Rosendale: Prevention of Future Deaths Report

1) Flixton Road Medical Centre 
2) Greater Manchester Integrated Care Board

I am Alison Mutch , senior coroner, for the coroner area of Manchester South  

I make this report under paragraph 7, Schedule 5, of the  Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

On 1^st October 2024 I commenced an investigation into the  death of Louise Danielle ROSENDALE. The investigation  concluded at the end of the inquest on 17^th March 2025. The conclusion of the inquest was accidental death. The medical cause of death was 1a) Multiple drug toxicity and Pneumonia. 

Louise Danielle Rosendale was prescribed long term opiates for pain following previous surgery. On 24th September 2024 she was found unresponsive at [REDACTED]. A post- mortem found she had died from a combination of multiple  drug toxicity and pneumonia.  

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  –  

THE INQUEST HEARD EVIDENCE THAT Louise Rosendale  had been prescribed opiates for many years despite the risks  associated with long term opiate prescribing. The evidence  before the inquest was that there had been very limited  attempts to review the long term prescribing of opiates to her.  The inquest was told that she had been identified as a patient  on a long term opiate prescription in 2022. The next action had been a pharmacy review in July 2024. There was no evidence of long term detailed planning or oversight of these patients within the practice  

In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to  take such action.  

You are under a duty to respond to this report within 56 days of the date of this report, namely by 25^th June 2025. I, the  coroner, may extend the period. 
Your response must contain details of action taken or  proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Father of Mrs Rosendale on  behalf of the family who may find it useful or of interest. 
I am also under a duty to send the Chief Coroner a copy of your response.  
The Chief Coroner may publish either or both in a complete or redacted or summary form. They may send a copy of this report to any person who they believe may find it useful or of  interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.