Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0231, written 17 Jun 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jun 2015 |
|---|---|
| Reference | 2015-0231 |
| Deceased | Andre Mickley |
| Coroner | ARW Forrest |
| Coroner area | Lincolnshire (Central) |
| 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.
AR W Forrest tw, ercp, FRcpath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire 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: As PF Director of Pharmacovigilance MHRA, 151 Buckingham Palace Road, Victoria, London, SW1W 4SZ 1 | CORONER | am ARW Forrest, Senior Coroner for the Coroner's area of South Lincolnshire. 2 | CORONER’S LEGAL POWERS | 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. 3 | INVESTIGATION and INQUEST On 9" March 2015 | commenced an investigation into the death of Andre Roderick Stewart MICKLEY, age 36 years. The investigation concluded at the end of the inquest on 17" June 2015. The conclusion of the inquest was Narrative Conclusion. 4 | CIRCUMSTANCES OF THE DEATH Andre was a long term multiple drug user who had used Methadone, Cocaine, Diazepam, Heroin and Pregabalin for several years without major ill effects. On the morning of 7 February 2015 he used heroin and cocaine. He collapsed shortly thereafter, suffering a massive subarachnoid haemorrhage. Despite neurosurgical intervention, he died on 23” February 2015. A few days before his collapse he had been prescribed Citalopram and this drug-and its metabolites were present in hospital admission blood samples, together with Cocaine, Methadone and Heroin metabolites. Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk AR W Forrest iu, ercp, FRcPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire 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. — 1 There are clear potentially adverse Pharmacokinetic interactions between Cocaine and the SSRI group of drugs, as well as case reports. (e.g. FU K.et al. ). Journal of Analytical Toxicology. 24C7):648-50, 2000). In general, the Summary of Product Characteristics (SPC) and the Patient Information Leaflet (PIL) do not suggest prescribers seek a history of substance misuse or patients exert caution and seek advice before prescribing or using medicines that have the potential to interact adversely with drugs of misuse. This includes adverse interactions other than just those between SSRI and cocaine ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and/or 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 13° August 2015. |, 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: 1. Andre's partner, i | am also under a duty to send the Chief Coroner a copy of your response. Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk A R W Forrest uu, rcp, FrePath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire 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 time of your response, about the release or the publication of your response by the Chief Coroner. ARW Forrest H M Senior Coroner for South Lincolnshire Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk
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