Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0156, written 20 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Mar 2026 |
|---|---|
| Reference | 2026-0156 |
| Deceased | Lee Adams |
| Coroner | Julian Morris |
| Coroner area | London Inner (South) |
| Category | Mental Health 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 (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
, Chair of Council, Royal College of
General Practitioners, Royal College of General Practitioners
30 Euston Square, London NW1 2FB
1
CORONER
I am Dr Julian Morris, senior 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 28 July 2020, I commenced an investigation into the death of Lee Derek Jamie
ADAMS, aged 36. The investigation concluded at the end of the inquest on 7 November
2025. The conclusion of the inquest was that:
[taken from Section 4 of the Record of Inquest]
Lee was suffering from a long-term depressive illness. He also partook in on-line
gambling. On 24.7.2020 he took an excessive number of propranolol tablets, intending
to take his own life. In the preceding few months - in Covid lockdown - he had become
increasingly reliant and involved with gambling. He was contacted in late March about
his deposits, he had stated he was fine. He continued to gamble. He was not identified
as being at increased risk.
I concluded Lee’s medical cause of death [Section 2] to be:
1a. Cardiac arrhythmia
1b. Propranolol overdose
1c. Gambling disorder
II. Depressive illness
4
CIRCUMSTANCES OF THE DEATH
Lee was at home alone and had been gambling extensively over the evening/night/ early
morning of 23/24 July 2020. The last time propranolol had been given by prescription
was in 2017; it was not clear where he had obtained the medication.
He called 999 in the early hours saying he had taken some
origin, an ambulance was dispatched arriving on scene some 10 minutes later and then
with him 23 minutes later. As, by that time, Lee had been unable to let the crew in, and
the police were tasked with assisting and gaining entry. By the time of entry, Lee status
had deteriorated significantly: seizing and with shallow breathing. In a short time, CPR
had to commence. At this stage the tableted medication was still unknown; naloxone
was given once, to no effect. Sadly, he was pronounced dead at 03.39
tablets of unknown
Subsequent post-mortem and toxicology revealing the presence of propranolol in Lee
stomach and blood. Expert evidence provided to the court was that once the significant
amount of Beta-Blocker had been taken (propranolol) the outcome was inevitable; there
being no opportunity to save his life.
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 send the report:
The MATTERS OF CONCERN, and heard by the court were as follows:
(1) Propranolol is absorbed quickly (the court heard within 30-60 minutes of ingestion)
and dose related.
(2) As a drug it is very effective in what it is prescribed for being used for, for example, in
the community to treat hypertension, anxiety and migraines. BUT unfortunately, it is
highly toxic at even small doses.
(3) There is no specific anti-dote to a propranolol overdose, the only form of treatment is
supportive and therefore hospital based.
(4) GPs should be aware of the consequences, at relatively small doses, of excess
propranolol ingestion; especially when there is no specific anti-dote and treatment is
restricted to supportive measures only.
(5) GPs should be reminded to ask individuals about their gambling habits in the same
way that they ask about smoking and alcohol.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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 Friday 15th of May 2026. 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
(Family Representative) – Leigh Day Solicitors
(GP Representative) – Clyde & Co Solicitors
– Bevan Brittan
Solicitors
Keystone Law, Counsel
I have also sent it to Royal College of Psychiatrists – Addictions Faculty and Gambling
Commission who may find it useful or of interest.
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.
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
[DATE] [SIGNED BY CORONER]
20.03.25 Dr Julian Morris, Senior Coroner
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.
Vice Chair Member Standards Dr Julian Morris Senior Coroner for the coroner area of London Inner South 14 May 2026 Dear Dr Morris Regulation 28 Report to Prevent Future Deaths - regarding the death of Mr Lee Derek Jamie Adams Thank you for asking us to comment on the matters of concern following the sad death of Mr Lee Derek Jamie Adams, who died on the 28th of July 2020. Our sincere condolences go to his family and friends given the difficult circumstances and the ongoing questions on how this could have been prevented. We will address the issues raised as requested in the hope that the response can help answer the concerns of the Coroner and Mr Adams’ loved ones. You have two matters of concern for GPs relating to this tragic death: • GPs should be aware of the consequences, at relatively small doses, of excess propranolol ingestion; especially when there is no specific anti-dote and treatment is restricted to supportive measures only. • GPs should be reminded to ask individuals about their gambling habits in the same way that they ask about smoking and alcohol. To give context to the family, The Royal College of General Practitioners works to improve patient care by encouraging the highest possible standards in general medicine practice by supporting members, setting standards, providing education and training, promoting research, advocating and representing the College and its 56,000 members. General Practitioners have a broad curriculum, and the College is responsible for the definitive educational framework for all doctors undertaking GP speciality training. There are 5 areas of capability aligned to the General Medical Council’s Generic Professional Capabilities Framework, and these are supported by twenty-two Clinical Topic Guides. Within the Mental Health Clinical Topic guide areas of a GP’s role include aspects relevant to Mr Adams’ care: Take account of psychosocial factors, including cultural background, bereavement, unemployment, relationship problems, alcohol and substance misuse, and gambling and Assess risk to make the patient’s safety and the safety of yourself and others a priority. Be aware that risk assessment is important but that there are no validated scales that predict suicide Royal College of General Practitioners 30 Euston Square, London, NW1 2FB Tel: 020 3188 7400 | info@rcgp.org.uk | rcgp.org.uk Registered Charity Number 223106 | Patron: His Majesty King Charles III This risk assessment includes the comprehensive approach of reviewing the level of risk of existing medications for both mental and physical health and their toxicity in overdose. The RCGP has been aware of the risks of Propranolol toxicity and responded to the HSSIB safety investigation to produce a ‘5 minutes to change your practice’ learning resource for GP members on the risks associated with prescribing Propranolol. I have not been provided with information regarding any risk assessments or consultations with the GP in Mr Adams’ care. Unfortunately, there is no information provided on where Mr Adams’ Propranolol supply was sourced, indicating an element of self-harm risk beyond what can be controlled from medication issued by a GP Practice. Awareness of self-harm thoughts or plans allow the GP an opportunity to reduce the amounts of harmful medications supplied as part of an initial risk reduction strategy, alongside additional mental health support, with the aim of suicide prevention. In addition to the GP curriculum, the RCGP Gambling Harms Hub is available for our members which encourages our members to complete the elearning course and webinar to be eligible to become a Gambling Harms accredited practice, with an established practice lead who is sent a staff training research pack that is intended for sharing with the practice team. Gambling Harms Accreditation: • Shows enhanced commitment to improving health outcomes for patients experiencing gambling harms • Sharing key learning points from learning with the wider practice team • Reducing stigma by broaching gambling in consultations, where relevant • Signposting patients to support, where needed • Displaying resources in the waiting room and public areas This helps to demonstrate how significantly the College perceives the harms of gambling and associated behaviours that impact on patients and families. Once again, our condolences go to Mr Adams’ family and friends. I hope the comments provide a full picture of where the RCGP can influence the prevention of future deaths within training and continuing professional development. Yours faithfully Vice President Member Standards
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