Thomas Kingston: Prevention of Future Deaths Report
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Date of report: 07/01/2025
Ref: 2025-0007
Deceased name: Thomas Kingston
Coroners name: Katy Skerrett
Coroners Area: Gloucestershire
Category: Suicide (from 2015)
This report is being sent to: National Institute for Health and Care Excellence | Medicines and Healthcare Products Regulatory Agency | Royal College of General Practitioners
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: The National Institute for Health and Care Excellence (NICE) 3rd Floor, 3 Piccadilly Place, Manchester, M1 3BN Emailed address: [REDACTED] The Medicines and Healthcare Products Regulatory Agency (MHRA) 10 South Colonnade, London E14 4PU Email address: [REDACTED] The Royal College of General Practitioners (RCGP) 30 Euston Square, London NW1 2FB Email address: [REDACTED] | |
| 1 | CORONER I am Katy Skerrett, Senior Coroner for Gloucestershire. |
| 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 the 26th February 2024 I commenced an investigation into the death of Thomas Henry Robin Kingston. The investigation concluded at the end of the inquest on the 3rd December 2024. The conclusion of the inquest was a narrative conclusion; see below Mr Kingston took his own life using a shotgun which a caused a severe traumatic wound to the head. Intent remains unclear as the deceased was suffering from adverse effects of medications he had recently been prescribed. The medical cause of death was 1A Traumatic wound to head. |
| 4 | CIRCUMSTANCES OF THE DEATH The deceased was a 45 year old man who was visiting his parents in Kemble Gloucestershire for the weekend. He had recently been experiencing anxiety, but had not expressed any suicidal ideation. On Sunday 25th February 2024 after lunch he began to unload his car, and prepared to return to London. Between approximately 1700-1800 hours he removed a shotgun from his vehicle which he had recently borrowed from his father for a shoot. He then accessed an annex attached to his parent’s property. Within a locked bathroom he self inflicted a gun shot to the head, and sustained injuries incompatible with life. He was subsequently found by his father. He was pronounced deceased at 1854 hours by attending police, who confirmed there were no suspicious circumstances surrounding his death. |
| 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 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. – 1. Whether there is adequate communication of the risks of suicide associated with the selective serotonin reuptake inhibitor (SSRI) medications, and 2. Whether the current guidance to persist with SSRI medication or switch to an alternative SSRI medication is appropriate when no benefit has been achieved and/ or especially when any adverse side effects are being experienced. |
| 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 4pm on 3rd March 2025. 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 1. [REDACTED], counsel for the family of Thomas Kingston, 2. [REDACTED] counsel for the GP, [REDACTED] 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 7 January 2025 Signature Ms K Skerrett His Majesty’s Senior Coroner for Gloucestershire |