Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0194, written 29 Apr 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Apr 2014 |
|---|---|
| Reference | 2014-0194 |
| Deceased | Dafydd Watts |
| Coroner | T G Moore |
| Coroner area | Avon |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
4. UCB Pharma
2. British National Formulary
CORONER
lam Mr. T. G. Moore, Assistant Coroner, for the area of Avon.
CORONER'S LEGAL POWERS
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.
INVESTIGATION and INQUEST
On| commenced an investigation into the death of Dafydd Rhys WATTS, Aged 34. The
investigation concluded at the end of the inquest on 14th March 2014. The conclusion of
the inquest was;
la Pericarditis
Ib Drug reaction with eosinophilia and systemic symptoms
syndrome (DRESS)
Ic Epilepsy treated with levetiracetam
Conclusion: Dafyyd Watts died suddenly of pericarditis following an
unrecognised and exceptionally rare drug reaction to his necessary anti-epileptic
treatment
4
| CIRCUMSTANCES OF THE DEATH
The deceased died of eosinophilic pericarditis and DRESS syndrome due to
Levetiracetam.
He had previously been prescribed Carbamazepine but suffered pulmonary eosinophilia.
He ceased this treatment and started Levetiracetam.
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
Although the evidence suggests that this is only the fourth such death documented it
appears that the possibility (albeit remote) of such an occurrence is not drawn to
physicians attention in the drug literature or in the BNF entry.
ACTION SHOULD BE TAKEN
in my opinion action should be taken to prevent future deaths and | believe your
organisation have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 26th June 2014. 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.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following interested
Persons — family, North Bristol! NHS Trust, University Hospitals NHS Trust and the GP.
| 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. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the {ime of your
response, about the release or the publication of your response py the ief Coroner.
29™ April 2014 Mr. T. G. Moor
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