Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0319, written 17 Jun 2024. 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 2024 |
|---|---|
| Reference | 2024-0319 |
| Deceased | Stefan Walker |
| Coroner | Edward Ramsay |
| Coroner area | Swansea and Neath Port Talbot |
| Category | Alcohol, drug and medication related deaths · Wales prevention of future deaths reports (2019 onwards) · Emergency services related deaths (2019 onwards) |
| 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. , CHIEF EXECUTIVE, WELSH AMBULANCE SERVICES UNIVERSITY NHS TRUST 1 CORONER I am EDWARD RAMSAY, His Majesty’s Assistant Coroner for the coroner area of SWANSEA AND NEATH PORT TALBOT. 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 JULY 2020 the Senior Coroner commenced an investigation into the death of STEFAN WALKER aged 40 (hereafter “STEFAN”), who died on 29 June 2020. The investigation concluded at the end of the inquest held between 20th and 28th May 2024. The said investigation was one to which the enhanced investigative obligation, under Article 2 of the European Convention on Human Rights, applied. The conclusion of the inquest jury was that STEFAN’S death was ‘Drug related’ – the medical cause of death being ‘buprenorphine and flualprazolam intoxication, and cardiac enlargement’ and that, inter alia, ‘Stefan died in his bedspace at Cefn Coed Hospital, Swansea on 29 June 2020 sometime between 1520 and 1545’. 4 CIRCUMSTANCES OF THE DEATH (1) At the time of his death STEFAN was a detained patient under the Mental Health Act 1983 and receiving in-patient psychiatric treatment on Fendrod Ward on account of his diagnosis of polysubstance misuse, psychosis, Emotionally Unstable Personality Disorder, and ADHD. (2) The evidence that I and the jury heard was to the effect that on both 28th and 29th June 2020 there were concerns that STEFAN had consumed illicit substances and was displaying symptoms of being physically unwell (overly sedated and drowsy, slurring his speech and tripping over his feet, unable to keep his eyes open and perspiring profusely). He disclosed to staff that he had taken ‘street diazepam’. (3) In the afternoon of 29 June 2020 he was found unresponsive in his room and attempts were made by nursing staff and paramedics to resuscitate him. The evidence and the jury heard was that STEFAN was displaying no signs of life when he was found. (4) Naloxone and Flumazenil were both administered by a junior doctor and the ward pharmacist with the assistance of the paramedics when they arrived – the Flumazenil only because it was kept on the ward. It was not carried by the paramedics, and I was told that it is not carried by paramedics. (5) Toxicology after his death revealed the presence of both buprenorphine (strong opioid analgesic) and flualprazolam (novel designer benzodiazepine). (6) Flumazenil is a potential antagonist in relation to the novel designer benzodiazepine. 5 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 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. – (1) I was told that paramedics and ambulance crew do not carry flumazenil (but often do carry naloxone). The availability of flumazenil was happenstance in this case because STEFAN was on an acute psychiatric ward where the said antagonist was being kept and could be prescribed by the ward pharmacist and administered by the doctors (with the support paramedics when they arrived). (2) I am concerned that there may be other acute circumstances when the use of this particular antagonist (flumazenil) could make a difference (say in the case of the collapse of person on the street or otherwise in the community) but will not be available since paramedics do not it. (3) I and the jury heard no evidence as to why naloxone is carried, but other antagonists (such as flumazenil) not. 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 12 AUGUST 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 (1) STEFAN’S Family (2) Swansea Bay University Health Board (3) City and Council of Swansea 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 other 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. 9 17 June 2024 EDWARD RAMSAY HM ASSISTANT CORONER FOR SWANSEA AND NEATH PORT TALBOT
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.
Cadeirydd Chair: Prif Weithredwr Chief Executive: Swyddfa'r Prif Weithredwr a’r Cadeirydd Chair and Chief Executive’s Office Our ref: Your ref: 17 July 2024 FAO: Edward Ramsay Assistant coroner for Swansea and Neath Port Talbot By email only to: Dear Mr Ramsay, Re: Inquest into the death of Stefan Barrie Walker I am writing in response to the Regulation 28 Report to Prevent Future Deaths, that you issued on 17 June 2024. On receipt, the report was passed to our Associate Medical Director for Emergency Care (who is a Consultant in anaesthesia, intensive care medicine & pre-hospital emergency medicine) and our Executive Director of Paramedicine. Advice and consultation with the National Ambulance Service Medical Directors Group (NASMeD) has also been sought in order to give your report our fullest consideration. As you are aware, flumazenil is a drug which acts to reverse the effects of benzodiazepine drugs (such as diazepam, midazolam, and similar agents). The drug ‘naloxone’ to which you also refer is a drug which reverses the effects of opioid drugs (such as morphine, heroin, fentanyl, etc). Naloxone is routinely carried by ambulance crews and can be administered by paramedics & emergency medical technicians. It is also carried by several UK police forces, and issued to members of the public who may come into contact with patients who are experiencing the effects of opioid overdose, as part of a wider strategy to reduce harm. Naloxone in this context has an excellent safety profile and there is extensive experience of use across the world. Mae’r Ymddiriedolaeth yn croesawu gohebiaeth yn y Gymraeg neu’r Saesneg, ac na fydd gohebu yn Gymraeg yn arwain at oedi The Trust welcomes correspondence in Welsh or English, and that corresponding in Welsh will not lead to a delay www.ambulance.wales.nhs.uk Pencadlys Rhanbarthol Ambiwlans Regional Ambulance Headquarters Beacon House William Brown Close Llantarnam, Cwmbran NP44 3AB Ffôn/Tel There are very robust clinical reasons as to why flumazenil cannot and should not be considered in the same way. While flumazenil does reverse the effects of benzodiazepines, its use for overdosage of benzodiazepines (and in particular overdose in the context of multiple drugs including benzodiazepines) is controversial and potentially very hazardous. Flumazenil has multiple serious side effects including life-threatening heart rhythm disturbances, and seizure activity. It also has drug interactions with many commonly used medications. The use of flumazenil is contraindicated in patients with seizures who are normally controlled with benzodiazepines & it must be used with great caution in patients who have prolonged use of benzodiazepines for any reason. The UK licenced indication for flumazenil is the “reversal of sedative effects of benzodiazepines in anaesthesia and clinical procedures”. Any use in other circumstances would be outside of the scope of the UK product licence and would not be something we could legally authorise for paramedic use. The view of our Associate Medical Director for Emergency Care is that flumazenil should not be carried for use in the context of suspected benzodiazepine overdose, and that supportive treatment should be provided instead. This advice was echoed by his colleagues at NASMeD. This is also the advice of the National Poisons Information Service (NPIS) who published guidance suggesting that flumazenil should be used only to “avoid mechanical ventilation in patients who developed reduced ventilation and coma due to GABA-A agonists”. (GABA-A receptors are the mechanism through which benzodiazepines have their effect). They go on to explicitly state that flumazenil “SHOULD NOT be used as a diagnostic test for benzodiazepine poisoning” or where the risk of convulsions is high, such as patients who have prolonged exposure to benzodiazepines over time, or where other potentially pro-convulsant drugs may have been taken (for example tricyclic antidepressant drugs). To address your specific matters of concern from the report: “I was told that paramedics and ambulance crew do not carry flumazenil (but often do carry naloxone). The availability of flumazenil was happenstance in this case because STEFAN was on an acute psychiatric ward where the said antagonist was being kept and could be prescribed by the ward pharmacist and administered by the doctors (with the support paramedics when they arrived). “ Some of our Welsh Ambulance Service paramedics do carry flumazenil and may utilise it under a patient group directive (PGD) authority. But this use is specifically only for the emergency reversal of benzodiazepines which they have administered, so this only applies to paramedics who are trained and authorised to use advanced sedative pain-relieving drug options. These paramedics however can (and should) only use flumazenil in this specific context, and the PGD is explicit that it should not be used in the context of other suspected benzodiazepine overdose for the reasons outlined above. “I am concerned that there may be other acute circumstances when the use of this particular antagonist (flumazenil) could make a difference (say in the case of the collapse of person on the street or otherwise in the community) but will not be available since paramedics do not it. “ Hopefully the explanation I have provided above will reassure you that flumazenil should not be used in this context based on all current clinical guidelines. Ambulance personnel are trained in advanced airway techniques and other supportive care strategies which are more appropriate for the management of benzodiazepine overdose. “I and the jury heard no evidence as to why naloxone is carried, but other antagonists (such as flumazenil) not.” Again, hopefully my explanation above will provide you with sufficient reassurance around this question. Naloxone has a long established and proven safety record and can and should be made widely available for the management of potential opioid overdose. Flumazenil by contrast would be unsafe for deployment in this manner and against all current published clinical guidelines. In closing, I hope this letter provides you with the information you require. However, if you have any further questions please do not hesitate to contact me, this can be done by writing to the address shown on this letter or by email to While writing I would like to offer my sincere condolences to Mr Walker’s family on their sad loss. Yours sincerely Chief Executive
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