Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0157, 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 | 2026-0157 |
| 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.
, Chief Executive, Medicines and Healthcare products
Regulatory Agency (MHRA), 10 South Colonnade, London
E14 4PU
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) Doctors and specifically 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.
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.
10 South Colonnade Canary Wharf London E14 4PU United Kingdom gov.uk/mhra Dr Julian Morris Senior Coroner Southwark Coroners Court 1 Tennis Street London SE1 1YD j 14 May 2026 Dear Dr Morris Regulation 28: Report to prevent future deaths, Lee Derek Jamie Adams Thank you for submitting a Regulation 28 Report to Prevent Future Deaths in relation to your investigation into the tragic death in July 2020 of Lee Derek Jamie Adams aged 36 from a propranolol overdose. Mr Adams had last been prescribed propranolol in 2017 and it was unclear where he had obtained the tablets that he took. Your report outlines the following matters of concern: 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) Doctors and specifically 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. The Medicines and Healthcare products Regulatory Agency (MHRA) is responsible for regulating medicines, medical devices and blood components for transfusion and for ensuring the safety, quality and effectiveness of these products throughout their lifecycle. The MHRA approved product information for healthcare professionals on the safe use of medicines is provided in the Summary of Product Characteristics (SmPC) and for patients in the Patient Information Leaflet (PIL) that accompanies the medicine. Propranolol is an effective medicine and the balance of benefits and risks is favourable when the guidance in the product information is followed. The SmPC states that ‘Propranolol is known to cause severe toxicity when used in overdose. Patients should be informed of the signs of overdose and advised to seek urgent medical assistance if an overdose of propranolol has been taken.’ The PIL states that ‘Propranolol is severely toxic if used in overdose. If you have accidently taken more than the prescribed dose or are experiencing symptoms of overdose, you should urgently seek medical attention. If you accidentally take an overdose of your medicine, either call your doctor straight away, or go to your nearest hospital casualty department. Always take any remaining tablets, the container and the label with you, so that the medicine can be identified.’ In February 2020 the Healthcare Safety Investigation Branch (HSIB) published a report on harms from propranolol (Potential under-recognised risk of harm from the use of propranolol) and issued recommendations to the BNF and NICE to update their guidance in relation to the use of propranolol in anxiety with particular reference to toxicity in overdose. The report also recommended that a number of healthcare professionals and healthcare system bodies take actions to address this issue. Since then a number of Trusts have issued guidance to clinical teams on the risks of propranolol prescribing in relation to its toxicity in overdose. In response to your matter of concern that ‘Doctors and specifically 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’ we are currently evaluating whether an article in the MHRA’s safety bulletin for healthcare professionals ‘Drug Safety Update’ would be an effective way to further increase the awareness of doctors of the risks of propranolol in overdose. Yours sincerely, Deputy Director, Benefit Risk Evaluation I Medicines and Healthcare products Regulatory Agency
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