Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0606, written 4 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Dec 2025 |
|---|---|
| Reference | 2025-0606 |
| Deceased | Samuel Brown |
| Coroner | Abigail Combes |
| Coroner area | South Yorkshire (East) |
| 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.
MS N J MUNDY H M CORONER SOUTH YORKSHIRE (East District) email: CORONER’S COURT AND OFFICE CROWN COURT COLLEGE ROAD DONCASTER DN1 3HS Date: 4 December 2025 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: NHS South Yorkshire Integrated Care Board CORONER I am Abigail Combes for South Yorkshire East 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. 1 2 http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 12 June 2025 I commenced an investigation into the death of Samuel Martin BROWN. The investigation concluded at the end of the inquest . The conclusion of the inquest was 3 Drug related death 1a Drug Intoxication CIRCUMSTANCES OF THE DEATH This case relates to the death of a2 29 year old male found deceased at Elliott Court, Rotherham on 30 March 2025. He had registered with a new GP practice approximately 6 weeks prior to his death. In evidence that practice recognised that there was a need for a medication review as Samuel was in receipt of a significant number of medications for pain which he may no longer require. The previous GPs appear to have continued to add medications to Samuel's primary care prescription list and he was therefore able to routinely access medications to which he was addicted. His death was as a result of drug intoxication and a number of those drugs were ones which were prescribed by the GP. Samuel's family are concerned that his medication was not adequately monitored by general practice and his drug seeking behaviour, linked to his addiction, was not appropriately managed by primary care. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my 4 5 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. – As the commissioners for primary care services I am concerned that the prescribing regime in primary care did not identify potential addiction and drug seeking behaviour or review medications with a view to checking they are actually required. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you the NHS South Yorkshire Integrated Care Board 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 22nd January 2026. I, the coroner, may extend the period. 7 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, , RDaSH and Gateway Primary Care. 8 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. 4 December 2025 9 Assistant Coroner for South Yorkshire East
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.
NHS South Yorkshire Integrated Care Board Management Office 197 Eyre Street Sheffield S1 3FG 19 January 2026 Abigail Combes Assistant Coroner South Yorkshire (East District) Coroners Court and Office Crown Court College Road Doncaster DN1 3HS Dear Coroner REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: Samuel Martin BROWN Thank you for your letter of 4 December 2025 I am writing in response to the Regulation 28 report to prevent future deaths, following the inquest into the sad death of Samuel Martin Brown, which you issued to: 1. The South Yorkshire Integrated Care Board, 722 Prince of Wales Road, Sheffield S9 May I firstly share our condolences to the family of Mr Brown and hope that the response below assists in providing reassurance that we are committed to delivering services that meet the needs of our South Yorkshire residents. The response below is on behalf of NHS South Yorkshire Integrated Care Board (NHS SY ICB), in its capacity as the statutory organisation responsible for commissioning primary care services. Within your report you asked for a response from NHS SY ICB, with regard to the following area of identified concern and the details of actions taken or proposed and timelines that we are taking to put in place improvements. 1. As the commissioners for primary care services I am concerned that the prescribing regime in primary care did not identify potential addiction and drug seeking behaviour or review medications with a view to checking they are actually required. Opioid and Dependence forming medication NHS SY ICB, under its current role, convene and lead a multidisciplinary Opioid Safety Group (OSG) with representatives including GPs, Pain Management Consultants, pharmacists and professionals from Substance Misuse Services and Local Authorities. The aims of this multidisciplinary meeting are to prevent avoidable harm caused by prescribed opioids, reduce the number of patients taking long-term opioids for non-cancer pain and reduce the number of patients on high dose opioids. South Yorkshire Integrated Care System's (ICS) joint efforts to tackle long-term opioid prescribing in non-cancer pain have reduced this from being the 2nd highest ICB area in 2023 to the 10th highest in 2025. However, we acknowledge that we still have work to do as with rates of 19.61 patients per 1000 on long-term opioids, compared to the national average of 14.2 patients per 1000, as of November 2025. The high levels of deprivation, significant burden of disease impacts on the levels of analgesics prescribing across South Yorkshire compared to more affluent areas. The OSG has developed a revised strategy for 2026-2030 for South Yorkshire ICS to drive opioid harm reduction by: • Setting system-wide goals and outcomes • Aligning ICS partners, including new partners (e.g. MNPs, IHOs) representing new footprints (e.g. Neighbourhoods) • Commissioning for prevention, impact and reducing health inequalities • Enabling local partnerships and provider collaboratives to lead local delivery To support the implementation of this complex work, NHS SY ICB has commissioned prescribing incentive schemes for primary care practices which include the review of patients on opioids to prevent avoidable harm. All three GP practices where the patient was registered have signed up to deliver the scheme for the last 2 years and are achieving above the 90% target. The OSG has developed a suite of prescribing resources to support Practices to review patients and where appropriate reduce the prescribing of opioids and co-prescribed opioids and gabapentinoids. They have also recently developed a template prescribing process for Primary Care that practices/prescribers can adopt and use to support good clinical practice. This will be available to all practices across SY in the next month. As part of NHS SY ICB transformation, the commissioning of pain management services is currently under review and will consider the learning from this case. The ICB must assist NHS England’s (NHSE) controlled drug accountable officer (CDAO) to carry out its functions under the Controlled Drugs (Supervision of Management and Use) Regulations 2013. We have undertaken a further review of the prescribing data provided by NHSE for the practices where the patient was registered covering 2022-2025 which has not identified any outlying concerns for opioid medicines. No incidents relating to controlled drugs have been reported to NHS SY ICB or NHSE Safeguarding On examination no concerns of safeguarding issues have been found for any of the registered practices. Polypharmacy NHS SY ICB have previously collaborated with NHSE to develop guidance for practices on how to record on their clinical system records, when a patient has been identified as having drug seeking behaviour. This is then visible to other healthcare services via the Summary Care Record (SCR) and can be used as a flag to healthcare professionals such as Out of Hours services and community pharmacies who may receive requests from patients and prevent inappropriate prescribing / supply of medicines. We are undertaking a review of the previous guidance and will then circulate to practices, include in bulletins / website. There are a number of polypharmacy materials to support review of patient on multiple medication that GP practices can use in any reviews of such patients. Shared leaning This Regulation 28 report to prevent future deaths and our response will be shared at the following forums, to seek any further opportunities for improvement and ensure lessons are learnt and shared wider than the involved practices: 1. Rotherham Place Partnership 2. South Yorkshire Patient Safety Group 3. South Yorkshire Opioid Safety Group 4. South Yorkshire System Mortality Oversight Group Meeting 5. South Yorkshire System Quality Group 6. NHS England Controlled Drug Accountable Officer North East & Yorkshire 7. North East & Yorkshire Regional Mortality Oversight & Learning from Deaths Group In closing, I wish to reiterate our shared commitment to ensure we are delivering high quality services for patients, carers and their families. Thank you for bringing these concerns to my attention. Yours Sincerely ICB Medical Director NHS South Yorkshire
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