Jason Brown: Prevention of future deaths report
Skip to related content
Date of report: 12/03/2024
Ref: 2024-0133
Deceased name: Jason Brown
Coroner name: David Place
Coroner Area: Sunderland
Category: Suicide (from 2015)
This report is being sent to: Lundbeck Limited | National Pharmacy Association | General Pharmaceutical Council | Medicines and Healthcare Products Regulatory Agency
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Lundbeck Limited National Pharmacy Association General Pharmaceutical Council Medicines and Healthcare Products Regulatory Agency | |
| 1 | CORONER I am David Place, His Majesty’s Assistant Coroner for the City of Sunderland |
| 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 3 | INVESTIGATION and INQUEST On 12th September 2022 I commenced an Investigation into the death of Mr Jason Brown, who was born on 28th November 1970 and who died at 3 Cheviot Lane, Sunderland on 6th September 2022 aged 51 years. The Investigation concluded at the end of an Inquest on 29th February 2024. The conclusion of the Inquest was ‘Suicide’. The medical cause of death was: Ia Cardiac Arrhythmia Ib Drug Overdose |
| 4 | CIRCUMSTANCES OF THE DEATH Jason Brown died at his home address of 3 Cheviot Lane, Sunderland on 6th September 2022 having taken an overdose of his medication. |
| 5 | CORONER’S CONCERNS During the course of the Inquest the evidence revealed a matter 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 MATTER OF CONCERN is: At the Inquest I heard evidence that prior to his death on 6th September 2022, Jason Brown received from the pharmacy his prescribed medication in a form of a full pack of [REDACTED] tablets of Zuclopenthixol dihydrochloride (clopixol). The pharmacy confirmed in evidence that this had been dispensed as a full pack in accordance with its special container status. Jason was prescribed his medication in weekly doses due to a history which included previous attempts to take an overdose of his medication. Jason received this full pack of [REDACTED] tablets only 17 days before taking an overdose of this medication on 6th September 2022. The pharmacy also confirmed that another patient at the practice received the same medication in a 7-day monitored dosage system (MDS) but could not confirm whether the remaining pack was then disposed of for that patient. I am concerned that, due to a special container status, a box of [REDACTED] tablets of [REDACTED] Zuclopenthixol dihydrochloride (clopixol) must be dispensed in its own special container as a full pack of tablets (original pack dispensing) and that this can endanger the safety of a patient with a history of suicidal risk and previous overdose attempts. Deaths may be prevented if the original pack dispensing guidance was reviewed for this medication. |
| 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 8th May 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: – Family and their Solicitors and Counsel Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust New Silksworth Medical Practice and the Solicitors and Counsel Demnox Pharmacy and their Solicitors and Counsel Herdman Pharmacy and their Solicitors and Counsel Care Quality Commission 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. |
| 9 | Dated this 12th day of March 2024 HM Assistant Coroner for the City of Sunderland |