A mother aged 33 from Sheerness in Kent died after an accidental overdose of the medicines she had been prescribed, an inquest has found. Coroner Ian Potter concluded that Carrie-Anne Sladden had been overprescribed medication and that she had not intended to overdose.

The inquest at Oakwood House in Maidstone, held on 4 and 5 November, heard that Ms Sladden had a complex medical history, including chronic pain, respiratory disease, mental health problems and Addison's disease, a rare condition in which the adrenal glands do not produce enough hormones.

At the time of her death in March 2025, she had been prescribed either 17 or 18 medicines. They included powerful painkillers, antidepressants, the sedative diazepam and pregabalin, which is used to treat nerve pain.

Review found no plan to cut medicines

Dr Christopher Olukanni, a clinical director at College Health, reviewed her medication in December 2024 and found she was taking 17 or 18 medicines. The inquest heard there was no coordinated plan to reduce the number of drugs she was taking.

Less than three weeks before she died, on 12 March 2025, Ms Sladden was prescribed the antidepressant citalopram as a replacement for trazodone, which she had been taking. The GP who prescribed it, Dr Pragasam of Sheerness Health Centre, told the inquest he considered citalopram safer and understood that she had already stopped taking trazodone.

Ms Sladden began feeling breathless in March 2025 and was initially told she could have a chest infection. She died of a cardiac arrest that month, on Mother's Day, according to reports of the inquest.

Serotonin syndrome and toxic drug levels

Toxicology tests found fatal concentrations of two antidepressants in her system. Both were capable of causing serotonin syndrome, a life-threatening condition in which too much serotonin builds up in the body.

The coroner recorded the medical cause of death as acute respiratory failure caused by lung injury, resulting from serotonin syndrome and polysubstance toxicity, the toxic effects of several substances acting together. He found that the overdose had not been intended.

The inquest heard that Ms Sladden could have been saved if the serotonin syndrome that killed her had been diagnosed and treated earlier. The coroner also found that a decision to downgrade an earlier call about her symptoms had been unsafe and had cost a chance for a face-to-face assessment.

Coroner's conclusion

Mr Potter concluded that Ms Sladden had been overprescribed and that the combination of medicines she was taking had proved fatal. The inquest did not find that she had intended to take her own life.

Her death has raised questions about how patients taking large numbers of medicines are monitored, and about whether warning signs of serotonin syndrome are recognised quickly enough when patients report new symptoms such as breathlessness.

Anyone affected by the issues raised in this report can contact their GP or pharmacist to discuss their medicines, or call NHS 111 for advice.