Robert Stevenson: Prevention of future deaths report

Alcohol, drug and medication related deathsSuicide (from 2015)

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Date of report: 07/06/2023

Ref: 2023-0180

Deceased name: Robert Stevenson

Coroner name: Martin Fleming

Coroner Area: West Yorkshire (Western)

Category: Suicide (from 2015) | Alcohol, drugs medication related deaths

This report is being sent to: Medicines & Healthcare products Regulatory Agency

1 Medicines & Healthcare products Regulatory Agency (MHRA)
I am M D FLEMING, HM Senior Coroner for the coroner area of West Yorkshire Western Coroner Area
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.
On 22/06/22 I opened an inquest into the death of Robert Newton Stevenson who, at the date of his death was aged 63 years old. The inquest was resumed and concluded on 25/5/23.  
I found that the cause of death to be:
1a. asphyxia (hanging)
I arrived at a narrative conclusion:
Robert Newton Stevenson intended to take his own life when the balance of his mind was disturbed.
Mr Stevenson was a 63 year old gentleman who was a very respected and experienced Consultant Cardiologist and General Physician at Huddersfield Royal Infirmary, who resigned his post in May 2022 to enter full retirement.   On 6/5/22 he was referred to the urology department for the investigation of possible prostate cancer, when a decision was also made to consult a private Consultant Urologist. In order to relieve his symptoms of prostatitis and to make him ready for an investigative biopsy, he was prescribed Ciprofloxacin on 19/5/22 at a dose of [REDACTED].
He had no previous history of depression or mental health problems.

Subsequently on the morning of 30/5/22 Mr Stevenson left his home address on his own for his usual walk. He had not previously given any indications to his family for them to be concerned for him. Thereafter at approximately 12.30pm his wife received a Facebook message from Mr Stevenson to indicate that he had left a note under the pillow of his bed.  

The note was found to be uncharacteristically confused and illogical given his reference to his baseless concerns that he may have developed AIDs after taking a HIV tester kit he had previously bought on line.  

Concerns were raised for his welfare, and this trigged an intensive police and family search of the surrounding area. Subsequently, Mr Stevenson was found hanging [REDACTED]. Upon the arrival of the paramedics, although resuscitative attempts were made, it was confirmed very sadly that he had passed away.
During the inquest I was referred by Mr Stevenson’s treating urologist to published literature relating to Ciprofloxacin and Quinolone antibiotics and a potential rare link to suicide behaviour in patients, although I found on the balance of probabilities that it remained unclear that he was suffering from this side effect, it remained possible for this to be the case.
The MATTERS OF CONCERN are as follows:
(brief summary of matters of concern)
•  I heard evidence to suggest that the prescribing doctor did not reference this side effect at the time of issuing the prescription to Mr Stevenson, since it was not in accord with current advice.
•  I also heard evidence to suggest that prescribing doctors may not be fully aware of this rare side effect, and that patient’s suffering from depression may be more vulnerable to it.
I am therefore concerned that this potential risk has not been given sufficient emphasis and I would ask you to consider the appropriateness of reviewing the current guidelines as to the dispensation of the drug to patients by clinicians and increasing the awareness of the side effect in order to monitor and mitigate the risks.
In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by August 01, 2023. 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.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons

Bayer PLC

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.
I may also send a copy of your response to any person who I believe may find it useful or of interest.
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.
HM Senior Coroner for West Yorkshire Western Coroner Area