Oxford Health Trust promises ‘learnings’ after drug death

Speaking at the inquest for Natasha Maria Ryan, held at Oxfordshire Coroner’s Court on Wednesday, April 22, a representative of the Oxford Health NHS Foundation Trust promised they were considering how they can take a more active approach to engagement with patients.

Ms Ryan had suffered ongoing mental and physical health problems but struggled to secure treatment with the trust and Coroner Darren Salter said he was concerned by the organisation’s lack of engagement.

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The 25-year-old was found dead by police in her Oxford bedroom at just past 2.30pm on July 3, 2025.

Born in Wandsworth, she was last seen on the 28 June by her boyfriend who raised the alarm with the police.

Mr Hussein had met her on an online dating app and the last time they were together was at the cinema.

He said: “She was in pain; she felt her body was giving up on her however the services that were meant to help her did not.”

Oxfordshire Coroner’s Court (Image: NQ)

Police officers attended her house just after midnight and then came back later in the day when they forced entry.

After her discovery a toxicology assessment found Tramadol in her system, a prescription-only opioid painkiller used to treat moderate to severe pain.

Around 3,700 nanograms per millilitre was measured which does constitute an overdose but is not considered a particularly high one.

The medication was prescribed to Ms Ryan who suffered from fibromyalgia a chronic disorder characterised by widespread musculoskeletal pain, fatigue, sleep disturbances and cognitive difficulties.

Bury Knowle Health Centre where Dr Gregory Lloyd is based (Image: Google Maps)

Despite this, it could not be determined for certain that she had taken her own life.

Mr Salter said: “I do not think there is sufficient evidence that Natasha took an overdose with the intention of taking her own life.”

She had previously overdosed on paracetamol in October 2024 for which she had been taken to hospital but since then it was not thought she had expressed suicidal thoughts.

Indeed at an appointment in June 2025 – the month of her death – with specialist nurse Sophie O’Keefe she seemed positive and said she wanted to return to education. 

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As well as fibromyalgia, Ms Ryan suffered from an eating disorder and though she was referred by her GP Dr Gregory Lloyd to the Oxford Health Trust’s complex needs team, she struggled to make her appointments either cancelling or missing them which she said was due to her chronic pain.

At one point she was discharged back to her GP because of this lack of engagement.

At the assessment with Ms O’Keefe she refused to be weighed which may have made it difficult for her to be transferred to the complex needs service, which requires a BMI.

In any case, at that time the waiting period for referral to the service was 18 months.  That has now come down to half a year.

Craig Heigold, paramedic and service manager at Oxford Health NHS Foundation Trust (Image: NQ)

Craig Heigold, a service manager at the trust, spoke at the inquest including about a ‘huddle report’ conducted after Ms Ryan’s death with all those involved in her care.

“There have been learnings from this,” he pledged.

He said they are reviewing how they can take a more active approach to engagement with a report set to be published in August this year.

The coroner, Mr Salter, said the lack of active engagement with her by the trust was a source of concern but that he was satisfied that it was being looked into.

Her uncle Matteo Cocomazzi was present and described her as “warm” and that she loved drawing and creating small items such as jewellery.

He said: “She continues to live in my heart and in my thoughts; she was a woman of great worth.”