Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0478, written 24 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Sep 2025 |
|---|---|
| Reference | 2025-0478 |
| Deceased | Mark Smith |
| Coroner | Sean Horstead |
| Coroner area | Essex |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: GP Partner, Addison House Surgery, Hamstel Road, Harlow Essex, CM20 1DS CORONER I am Sean Horstead, area coroner, for the coroner area of Essex 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 On 14th March 2024 I commenced an investigation into the death of Mark Alan SMITH, aged 50 years’. The investigation concluded at the end of the inquest on the 5th August 2025. The conclusion of the inquest was a Narrative Conclusion In the following terms: Mark Alan Smith took his own life, but the evidence does not establish to the required standard of proof his intent at that the time he consumed the fatal quantities of prescription medication and alcohol. The admitted failure of his GP Practice to review, adequately or at all, the clear risk involved in the continued prescribing of unnecessarily excessive quantities of sedative prescription medication in the context of Mr Smith’s extensive background of addiction and mental health issues, including anxiety and depression and a previous history of overdoses of prescribed medication, probably contributed more than minimally to the death. CIRCUMSTANCES OF THE DEATH Mark Alan Smith was found deceased on 5th March 2024 at his home address, 23 Church End, Harlow, Essex. He died following the ingestion of large quantities of prescription medication including Mirtazapine and Pregabalin 1 2 3 4 1 together with a very significant quantity of alcohol. Crews from the East of England Ambulance Service Trust (EEAST) attended Mr Smith’s home for around two and a half hours from around 04.00 hours on the 4th March (following concerns raised by family members that he had taken an overdose of prescription drugs). An EEAST crew reattended for around twenty minutes on the afternoon of the same day after Essex Police contacted EEAST following a call from Mr Smith’s mother that he was threatening to take his own life. On neither occasion was Mr Smith taken to Hospital. The last contact with family members was between 18.00 and 19.00 hours on the 4th March. Mr Smith was found deceased the following morning by his son. 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 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. – Evidence was received from two GP Partners at Mr Smith’s GP Practice. Both GPs confirmed that at the time of Mr Smith’s involvement with the Practice continuing up to and including the date of the inquest, there continued to be no system, policy or process in place, to ensure that vulnerable patients with a history of addiction and/or self-harm and/or suicidal ideation and/or prescription medication overdose received or receive appropriate medication reviews to consider the frequency and volume of repeat prescribed medication. It was conceded, accordingly, that there was - and remained - no policy or procedure in place to mitigate the clear risk involved in GPs prescribing unnecessarily excessive quantities of (potentially dangerous) prescription medication (at inappropriate frequency) to a clearly vulnerable cohort of patients, and therefore no policy or procedure is in place to minimise the danger of stockpiling of such medications and the concomitant risk of potentially fatal, (advertent or inadvertent), misuse of such medication. 6 7 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19.11.2025. I, the coroner, may extend the period. 2 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: The Family of the deceased. I have also sent it to the Hertfordshire and West Essex Integrated Care Board, The Forum, Marlowes, Hemel Hempstead, Hertfordshire, HP1 1DN who may find it useful or of interest. 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. She 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 24.09.2025 HM Area Coroner for Essex Sean Horstead 3
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.
Addison House & Barbara Castle Surgery Web site: www.addison-surgery.nhs.uk Addison House Health Centre Hamstel Road Harlow Essex CM20 1DS Partners: Barbara Castle Health Centre Broadley Road Harlow Essex CM19 5SJ 03 November 2025 Prevention of Future Deaths Report (Regulation 28) HM Area Coroner for Essex Sean Horstead Seax House Essex County Council Victoria Road South Chelmsford CM1 1LX Re: Prevention of Future Deaths Report (Regulation 28) In the matter of: Late Mark Smith, Date of Death: 5/3/24 Coroner's Area: Essex Thank you for your Report of 24/9/25 concerning the tragic death of Mark Smith. We extend our sincere condolences to his family and friends. We acknowledge the profound seriousness of this matter and appreciate the concerns you have raised. We are committed to learning from this event and implementing robust changes to minimise the risk of such a tragedy occurring in the future. This letter constitutes our formal response, as required within 56 days, detailing the actions we have taken and propose to take. Response to Matters of Concern: We address each of your specific concerns as follows: Evidence was received from two GP Partners at Mr Smith’s GP Practice. Both GPs confirmed that at the time of Mr Smith’s involvement with the Addison House & Barbara Castle Surgery Practice continuing up to and including the date of the inquest, there continued to be no system, policy or process in place, to ensure that vulnerable patients with a history of addiction and/or self-harm and/or suicidal ideation and/or prescription medication overdose received or receive appropriate medication reviews to consider the frequency and volume of repeat prescribed medication. There were safety provisions within the Practice’s repeat prescribing policy at the time of late Mark Smith’s death with multiple documented restrictions of inappropriate high risk medication requests by Mr Smith. The Practice has updated and strengthened the risk assessment provisions of repeat prescribing for identified patients with self-harm or suicide risk as well as monitoring of same with enhanced medication reviews/risk assessments. It was conceded, accordingly, that there was - and remained - no policy or procedure in place to mitigate the clear risk involved in GPs prescribing unnecessarily excessive quantities of (potentially dangerous) prescription medication (at inappropriate frequency) to a clearly vulnerable cohort of patients, and therefore no policy or procedure is in place to minimise the danger of stockpiling of such medications and the concomitant risk of potentially fatal, (advertent or inadvertent), misuse of such medication. There were safety provisions within the Practice’s repeat prescribing policy at the time of late Mark Smith’s death. The Practice has implemented changes to strengthen the risk assessment provisions of the repeat prescribing policy as well as monitoring of same. Summary of Actions Taken – The following actions have been undertaken: Immediate High-Risk Patient Review: A full audit of all patients registered at Addison House Surgery, coded at risk of self-harm/suicide and on repeat medications. Identified patients have had medication/risk reviews by the pharmacists with restriction of repeat medications to seven-day periods. Medication Safety Policy Enhancement: A comprehensive review and update of our Polypharmacy and High-Risk Prescribing Policy undertaken with two core prescribing updates – 1-Pharmacists to review all future correspondence received at the Surgery with identified risk of self-harm/suicide - high risk medications to be reduced to seven-day supply periods. 2 -Low risk patients to remain on 6-monthly medication reviews– high risk patients to be reviewed 3 monthly or sooner if deemed necessary by clinician until the risk is de-escalated by the mental health team. Addison House & Barbara Castle Surgery We have conducted an urgent review of our IT system's safety alerts. We have enhanced the triggers for alerts related to self-harm and suicide risk with high level reminders to be applied to all identified patients’ records. Governance Oversight: This incident and the associated action plans have been escalated to the Hertfordshire and West Essex ICB (integrated care board) Patient Safety team for ongoing monitoring. We have shared the learning from this case with our local healthcare system, including other GP practices (within our primary care network – Harlow North) and community clinicians affiliated to the Surgery (via multidisciplinary team meeting), to promote wider improvement. We are deeply sorry for the failings in the late Mark Smith’s care. We assure you that we have treated your report with the utmost seriousness and are committed to delivering sustainable change to enhance patient safety. GP Partner Addison House Surgery Hamstel Road Harlow CM20 1DS --- cc: · The Chief Coroner · Chair of the Local Clinical Commissioning Group/Integrated Care Board · Care Quality Commission (CQC) Addison House Surgery
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