A CORONER has called for better integration of GP and hospital services, at an inquest into the death of a 27-year-old woman.

Leesha Cairns from the Mount Estate, Milford Haven, died on February 19, 2017.

Almost 18 months later, a coroner has concluded the mother-of-one died as a result of diabetic ketoacidosis – a complication of diabetes - and combined prescription drug intoxication.

The inquest heard several multi-disciplinary meetings, involving GPs, pain management staff, diabetes and mental health professionals were held to try to determine why Ms Cairns was in hospital so often, particularly in the months before her death.

Dr Paul Underwood, who treated Ms Cairns for ketoacidosis several times, said these meetings were not standard practice, and during his career he had called them 'maybe twice'.

Coroner Mark Layton heard cross-ward measures were also put in place to limit the amount of extra pain relief given to Ms Cairns, who also suffered from chronic pain, endometriosis and fibromyalgia.

Ms Cairns' father Alan said he fully believed his daughter was addicted to Oramorph, and had raised concerns with her GP and hospital doctors.

Medical staff told the inquest Ms Cairns did not display signs of addiction, but the pain management team had spoken to her about reducing her long-term pain medication, in favour of a more therapeutic approach.

But when GP Kath Davies spoke to Ms Cairns in October 2016 about this plan, Ms Cairns denied she had agreed to it, saying Oramorph appeared to be the 'only thing making a difference'.

A letter from Dr Davies asking for clarification from the pain management team went unanswered, and so her medication remained the same until her death.

Mr Layton asked how patients could be sure services were working in harmony, when different departments were not immediately able to access full patient records.

"Ideally the system should be that when a patient comes in you type their name into a computer," he said.

Dr Underwood said that was also what doctors wanted.

"Wales is making good progress but it's not there yet, and it makes it difficult," he said.

Dr Davies also told Mr Layton that, due to historic delays in receiving discharge papers, GPs often only found out their patient had been in hospital when they next turned up at the surgery.

Mr Layton said Ms Cairns was a complex patient with multiple issues, which made it difficult for those treating her to effectively manage all her conditions.

But, he said, there was a 'need for greater integration of primary and secondary health services to improve patient care'.

“Progress is being made, I'm told, but there is much to do.”

Recording his conclusion, Mr Layton said Ms Cairns had a history of poorly controlled diabetes, resulting in multiple admissions to hospital for ketoacidosis.

There was also evidence she was not taking her insulin as prescribed.

Despite numerous tests, the reason for her chronic pain was never clearly diagnosed, “which left Leesha feeling frustrated and disillusioned”.

“She felt she was not being listened to,” said Mr Layton.