Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0189, written 8 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Apr 2024 |
|---|---|
| Reference | 2024-0189 |
| Deceased | Joshua Delaney |
| Coroner | David Manknell |
| Coroner area | London Inner (South) |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. National Medical Director, NHS England 1 CORONER I am David Manknell KC, Assistant Coroner, for the coroner area of London Inner South 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. 3 INVESTIGATION and INQUEST On 7 August 2020 an inquest was opened into the death of Joshua Arthur Stafford Delaney. The inquest was concluded on 28 March 2024. The medical cause of death was Propranolol toxicity. The jury’s conclusion at the inquest was a narrative conclusion, including a conclusion that the deceased took an overdose while conscious of what he was doing and that he intended to end his life, but that after the act he regretted his decision. 4 CIRCUMSTANCES OF THE DEATH The deceased, aged 19 at the time of his death, was a young man with a history of mental illness and suicidal ideation, and who had made previous suicide attempts. During the year prior to the index events, he had been prescribed Mirtazapine for anxiety and to help with sleep. Following his discharge from the Community Mental Health Team, he attended his GP in October 2019, with symptoms of anxiety and physical symptoms including palpitations and tachycardia. He was prescribed Propranolol days, and given to be taken times a day for tablets for this purpose. He was given further prescriptions of tablets of Propranolol at the beginning of November 2019, and again on 4 January 2020. He had seen his GP in early December 2019, who had intended that the deceased move to taking Propranolol ‘as required’ in order to wean him off its use. In the early hours of 19 January 2020, the deceased took a large overdose of Propranolol, estimated by the toxicologist to have been collapsed. Despite prolonged attempts at resuscitation by the paramedics and in hospital, he died on 19 January 2020. , and was found 5 CORONER’S CONCERNS During the course of the investigation and inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The evidence of the General Practitioner in this case was to the effect that prior to this death, neither he nor his colleagues were aware that Propranolol carried any significant risk of death through deliberate overdose. The evidence of the doctor in question was that because of this specific incident, there has been a change in their approach to 1 prescribing of Propranolol at his GP surgery, with smaller quantities prescribed to patients who might be at risk of taking an overdose. Shortly after this incident (11 February 2020) there was, coincidentally, an article in the British Medical Journal in respect of Propranolol, (“Doctors and paramedics must be better prepared to deal with propranolol overdoses”). However, the doctor’s evidence in the inquest was that he did not believe that GPs generally were currently aware of the risk of Propranolol overdoses. The evidence from the Consultant Psychiatrist from the Community Mental Health Team was that they would not usually prescribe Propranolol, and he also considered that GPs may not be aware of the overdose risk posed by the drug. The inquest also heard from the toxicologist, who gave evidence that her anecdotal experience was that there had in recent years been a significant number of deaths caused by Propranolol overdoses. In the circumstances, I am concerned that doctors in General Practice may not be aware of the risks of fatal overdose from Propranolol, and that in the absence of greater awareness by GPs, the prescription of quantities of Propranolol to those at risk may cause future deaths. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 3 June 2024. 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: and Maudsley NHS Foundation Trust, and the Metropolitan Police. , the South London I 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 time of your response, about the release or the publication of your response by the Chief Coroner. 9 8 April 2024 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mr David Manknell KC
HM Assistant Coroner
Inner South London Coroner Area
Southwark Coroner’s Court
1 Tennis Street
London
SE1 1YD
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
05/08/2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Joshua Arthur Stafford
Delaney who died on 19 January 2020.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8 April
2024 concerning the death of Joshua Arthur Stafford Delaney on 19 January 2020. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Joshua’s family and loved ones. NHS England are
keen to assure the family and the Coroner that the concerns raised about Joshua’s
care have been listened to and reflected upon.
I am grateful for the further time granted to respond to respond to your Report, and I
apologise for any anguish this delay may have caused Joshua’s family or friends. I
realise that responses to Coroner Reports can form part of the important process of
family and friends coming to terms with what has happened to their loved ones and
appreciate this will have been an incredibly difficult time for them.
Your Report raises the concern that doctors in General Practice may not be aware of
the risks of fatal overdose from Propranolol, and that in the absence of greater
awareness by GPs, the prescription of quantities of Propranolol to those at risk may
cause future deaths.
The National Institute for Health and Care Excellence (NICE) guidance on generalised
anxiety disorder and panic disorder in adults (published on 26 January 2011) does not
recommend the use of Propranolol in anxiety and there is no recommendation in the
British National Formulary (BNF), which provides key information for prescribers on
the selection, prescribing, dispensing and administration of medicines, to use
Propranolol for the treatment of anxiety in isolation. The BNF does however provide
dose information for Propranolol for the treatment of anxiety symptoms such as
palpitation, sweating and tremor, reflecting the licensed dose for these indications and
including information on the risk of overdose from Propranolol. Under the ‘important
safety information’ section, there is also reference to the Health Services Safety
Investigations Body (HSSIB) patient safety investigation from February 2020,
regarding the potential under-recognised risk of harm from the use of Propranolol.
My colleagues from NHS England’s National Patient Safety Team have been engaging
with NICE to flag the circumstances of Joshua’s death and inviting them to strengthen
their cautions around the use of Propranolol.
Following our review of this case, it has also been agreed that NHS England will issue
communications to GPs to reiterate that NICE do not recommend Propranolol as a
treatment option for anxiety, and emphasising the risks involved in its administration,
and we will do so as soon as practicable. NHS England are also engaging with the
Medicines & Healthcare Products Regulatory Agency (MHRA), who we understand
are also considering some communications on this issue. NHS England are happy to
update the Coroner in due course and once communications have been issued.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of
Joshua, are shared across the NHS at both a national and regional level and helps us
to pay close attention to any emerging trends that may require further review and
action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
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