Frances Newbury

Private & Confidential 
Ms Melanie Sarah Lee 
His Majesty’s Coroner 
Inner North London 

22 December 2023 

 London Ambulance Service 
Chief Executive Office 
Headquarters 
220 Waterloo Road 
London 
SE1 8SD 

www.londonambulance.nhs.uk 

Your Reference: Ann Newbury (deceased) / Inquest date 10th November 2023 

Dear Madam 

Thank  you  for  the  Prevention  of  Future  Deaths  report  issued  on  the  13th  November  2023  to  the  London 
Ambulance Service NHS Trust in relation to our attendance to Frances Ann Newbury on the 20th May 2023. 
We note that the PFD report raises concern in relation to naloxone administration in cardiac arrest. I would 
like to firstly like to extend my deepest sympathies on behalf of London Ambulance Service NHS Trust to Ms 
Newbury’s family and friends on their tragic loss.   

I am aware that London Ambulance Service NHS Trust received a query raised in relation to the administration 
of naloxone on the 8th November 2023 (two days prior to the listed Inquest date). I would like to apologise 
that we were not able to provide a response ahead of the inquest and we recognise that this may have assisted 
your investigation and provided an overview of expected practice.  

In order to inform this response, we have undertaken a detailed clinical review of the care provided. This has 
involved a Learning from Death review which identified that, whilst it is recognised that Ms Newbury had a 
  at 
history  of  drug  abuse,  the  attending  clinicians  were  advised  that  Ms  Newbury  had  taken 
around 2100 the previous evening.  There was no overt direct indication that Ms Newbury had taken opioids 
immediately preceding her death.  

Whilst it is recognised that Ms Newbury had a long term history of opioid use, naloxone was not considered 
at the time of the cardiac arrest as there was no immediate history of opioid use and a clinically feasible cause 
of the arrest was identified, which was a current infection. The resuscitation attempt focused on high quality 
chest compressions and effective ventilation. It was recognised by the clinicians that naloxone would not have 
reversed the effects of 
. The information reported to the clinicians at the time of attendance was 
that Ms Newbury had taken 

 the previous evening. 

Where a patient takes an ‘overdose’ of opioids the mode of cardiac arrest is one where there is depression of 
the  central  respiratory  drive,  leading  to  reduced  respirations  (breathing)  which  results  in cerebral  hypoxia 
(decreased  oxygen  within  the  brain  tissue).  Opioids  exert  their  analgesic  effects  predominately  through 
agonist binding at µ receptors in the brain and spinal cord. This produces the analgesic and euphoric effects 
often seen in patients who have taken an opioid. Where opioids have been taken in excessive amount, the 
result  can  cause  respiratory  depression  and  impair  sensitivity  to  hypoxaemia  (low  oxygen  in  blood) 

 
 
 
 
 
 
 
 
 
 
 
 
 /hypercarbia  (increased  levels  of  carbon  dioxide)  through  mechanisms  involving  µ  and  GABA-A  (γ-
aminobutyric acid A) receptors.  

Asphyxia (deprivation of oxygen), through the respiratory depression (reduction in an individual’s breathing), 
develops and this leads to further cerebral hypoxia. Ultimately it is the hypoxia/hypercarbia which cause a 
diminishing  cardiac  output  and  may  finally  sadly  result  in  a  patient’s  cardiac  arrest.  Where  a  patient  is  in 
cardiac arrest, there is immediate and ongoing artificial ventilation in an attempt to correct any ventilatory 
failure. Naloxone is a competitive antagonist (receptor site blocker) for the opioid and its administration aims 
to diminish the effects of the opioid, however, once a patient is in cardiac arrest (as opposed to respiratory 
arrest)  the  focus  should  be  on  high  quality  standard  life  support  including  artificial  ventilation,  chest 
compressions and adrenaline administration.  

Where a patient presents in cardiac arrest, the key aim is to attempt to restart the heart through artificial 
ventilation and chest compressions. Whilst it is recognised that naloxone has formed part of the resuscitation 
process for a number of years where opioid use is suspected, there are no randomised studies looking at the 
efficacy of naloxone in opioid-induced cardiac arrests nor evidence that naloxone will reverse cardiac arrest.  
It is highlighted that there are some reasonable concerns that by using naloxone this may detract clinicians 
from ensuring the most effective chest compressions are delivered. In essence it is the hypoxic/hypercarbic 
insult which has caused the cardiac arrest and naloxone will not facilitate the heart restarting.  

The 2015 American Heart Association Guidance details: 

 

 

It may be reasonable to administer intramuscular or intranasal naloxone based on the possibility that 
the patient is not in cardiac arrest. 

Standard resuscitative measures should take priority over naloxone administration, with a focus on 
high-quality Cardio Pulmonary Resuscitation (CPR chest compressions plus ventilation). 

  We  can  make  no  recommendation  regarding  the  administration  of  naloxone  in  confirmed  opioid-
associated cardiac arrest. Patients with opioid-associated cardiac arrest are managed in accordance 
with standard Advanced Cardiovascular Life Support (ACLS) practices. 

In the case of Ms Newbury, the ambulance clinicians were absolutely confident that she was in established 
cardiac arrest and that her cardiac arrest was unwitnessed. No clear timeframe of the arrest was able to be 
established and she was promptly identified to be in asystolic (absence of heart beat and electrical activity) 
arrest. 

The International Liaison Committee on Resuscitation (ILCOR) advised 

“We did not identify any studies reporting any critical or important outcomes of adults or 
children  with  suspected  opioid-associated  cardio  /  respiratory  arrest  in  any  setting, 
comparing  bystander  naloxone  administration 
intranasal)  plus 
conventional CPR, to conventional CPR only.” 

(intramuscular  or 

 
 A  recent  extensive  review  conducted  on  behalf  of  the  American  Heart  Association  published  in  2021 
concluded1  

“If the patient is definitely pulseless and receiving standard resuscitation, including assisted 
ventilation, naloxone is unlikely to be beneficial. Because there is a theoretical basis for harm, 
standard resuscitation alone is indicated. Opioid antagonism to prevent Opioid Associated 
(OA)  -Out  of  Hospital  Cardiac  Arrest  in  patients  with  OA  central  nervous  system  and 
respiratory depression is always reasonable and should be delivered along with CPR when it 
is uncertain whether the patient is pulseless.” 

Overall the evidence base suggests that where cardiac arrest is established and confirmed from opioid use, 
naloxone  has  limited  efficacy  in  reversing  the  cardiac  arrest.  The  Joint  Royal  Colleges  Ambulance  Liaison 
Committee (JRCALC) Clinical Practice Guidance advise the use of naloxone in cardiac arrest, noting that this 
has been unchanged and more recently the empirical reviews of the clinical evidence have been undertaken. 
I have asked that our Consultant Paramedics and Associate Clinical Directors who both are members of the 
JRCALC resuscitation group, request that a review is undertaken of JRCALC current guidance in light of the 
emerging clinical evidence, in respect of opioids.       

We do recognise that there may be some ‘novel’ synthetic opioids where the opioid in itself may cause a more 
marked direct myocardial depression than heroin and in these cases there may be an increased clinical need 
to consider naloxone in such arrest, although these agents are not usually drugs of recreational use or abuse 
and are very uncommon. In this area there is limited evidence upon which to base any recommendation. 

We would not be critical of a decision to administer naloxone in cardiac arrest as long as this does not distract 
from the essential, evidence based, aspects of life support which includes high quality chest compressions and 
artificial  ventilation.  Equally  where  an  informed  clinical  decision  is made  that the  patient  is  in  established 
cardiac arrest we would not be critical of a decision to focus on effective resuscitation. In this case there was 
no clear indication of opioid use immediately prior to the collapse, and Ms Newbury was in established cardiac 
arrest.  On  balance,  we  are  not  of  the  view that  naloxone  was  mandated  and  believe  this would  not  have 
changed the outcome.       

That said, the LAS is absolutely of the view that naloxone should be administered where a patient presents 
with respiratory depression and/or is peri (near) arrest, in this instance it is recognised to be lifesaving and we 
absolutely support its administration. In March 2022, the London Ambulance Service initiated the availability 
of high concentration naloxone on specialist resources utilised by the Trust. This was in recognition of the 
potential for highly potent synthetic opioids where stronger doses of naloxone may be required.  We are also 
highly supportive of naloxone in community programs, for those where there is a high risk of overdose.   

Whilst we recognise that this did not prevent the sad outcome in this case, we hope this assists in providing 
assurance that as a Trust we have taken a robust review of naloxone administration in this case and the wider 
use of naloxone in established cardiac arrest. 

We would be very happy to discuss and present the work the LAS is doing to improve cardiac arrest survival 
in  London.  This  includes  a  London  wide  programme  to  increase  early  bystander  life  support  as  well  as 

1 Dezfulian C, Orkin AM, Maron BA, et al. Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical 
Features and Implications for Health Care and Public Responses: A Scientific Statement from the American Heart 
Association. Circulation. 2021;143(16):e836-e870. doi:10.1161/CIR.0000000000000958 

                                                 
 increasing the accessibility to public access defibrillators and trained responders and we are working with our 
agencies who have regular contact with opioid users around utility of naloxone to be available to others.  

If you would like to take up this offer please contact 
Trust on resuscitation 

 Consultant Paramedic, who leads for the 

Yours faithfully 

Chief Executive Officer