Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0180, written 7 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jun 2023 |
|---|---|
| Reference | 2023-0180 |
| Deceased | Robert Stevenson |
| Coroner | Martin Fleming |
| Coroner area | West Yorkshire Western |
| Category | Suicide (from 2015) · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Medicines & Healthcare products Regulatory Agency (MHRA) 1 CORONER I am M D FLEMING, HM Senior Coroner for the coroner area of West Yorkshire Western Coroner Area 2 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 3 On 22/06/22 I opened an inquest into the death of Robert Newton Stevenson who, at the date of his death was aged 63 years old. The inquest was resumed and concluded on 25/5/23. I found that the cause of death to be: - 1a. asphyxia (hanging) I arrived at a narrative conclusion:- Robert Newton Stevenson intended to take his own life when the balance of his mind was disturbed. 4 CIRCUMSTANCES OF THE DEATH Mr Stevenson was a 63 year old gentleman who was a very respected and experienced Consultant Cardiologist and General Physician at Huddersfield Royal Infirmary, who resigned his post in May 2022 to enter full retirement. On 6/5/22 he was referred to the urology department for the investigation of possible prostate cancer, when a decision was also made to consult a private Consultant Urologist. In order to relieve his symptoms of prostatitis and to make him ready for an investigative biopsy, he was prescribed Ciprofloxacin on 19/5/22 at a dose of He had no previous history of depression or mental health problems. . Subsequently on the morning of 30/5/22 Mr Stevenson left his home address on his own for his usual walk. He had not previously given any indications to his family for them to be concerned for him. Thereafter at approximately 12.30pm his wife received a Facebook message from Mr Stevenson to indicate that he had left a note under the pillow of his bed. The note was found to be uncharacteristically confused and illogical given his reference to his baseless concerns that he may have developed AIDs after taking a HIV tester kit he had previously bought on line. Concerns were raised for his welfare, and this trigged an intensive police and family search of the surrounding area. Subsequently, Mr Stevenson was found hanging Upon the arrival of the paramedics, although resuscitative attempts were made, it was confirmed very sadly that he had passed away. 5 CORONER’S CONCERNS During the inquest I was referred by Mr Stevenson’s treating urologist to published literature relating to Ciprofloxacin and Quinolone antibiotics and a potential rare link to Regulation 28 – After Inquest Document Template Updated 30/07/2021 suicide behaviour in patients, although I found on the balance of probabilities that it remained unclear that he was suffering from this side effect, it remained possible for this to be the case. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) I also heard evidence to suggest that prescribing doctors may not be fully aware of I heard evidence to suggest that the prescribing doctor did not reference this side • effect at the time of issuing the prescription to Mr Stevenson, since it was not in accord with current advice. • this rare side effect, and that patient’s suffering from depression may be more vulnerable to it. • emphasis and I would ask you to consider the appropriateness of reviewing the current guidelines as to the dispensation of the drug to patients by clinicians and increasing the awareness of the side effect in order to monitor and mitigate the risks. I am therefore concerned that this potential risk has not been given sufficient 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by August 01, 2023. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Bayer PLC I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. 9 Dated: 07/06/2023 M D FLEMING HM Senior Coroner for West Yorkshire Western Coroner Area Regulation 28 – After Inquest Document Template Updated 30/07/2021
See every Prevention of Future Deaths report matching Suicide (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.