Source · Prevention of Future Deaths

Viktor Scott-Brown

Ref: 2020-0163 Date: 18 Aug 2020 Coroner: Oliver Longstaff Area: County Durham and Darlington Responses identified: 4 / 5 View PDF

A psychiatrist failed to inform a patient about Lamotrigine's self-harm/suicide side effect due to a lack of awareness, exacerbated by inconsistent or absent warnings in reputable pharmacological guidelines, posing patient safety risks.

Date 18 Aug 2020

56-day deadline 20 Oct 2020

Responses identified 4 of 5

Community health care and emergency services related deaths Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

The MATTERS OF CONCERNS are as follows:

Mr Scott-Brown was prescribed Lamotrigine by an NHS Foundation Trust Consultant Psychiatrist. The prescribing consultant did not give Mr Scott-Brown a Trust information sheet about Lamotrigine and a Patient Information Leaflet about Lamotrigine from the drug manufacturer, GlaxoSmithKline. It was common ground that the consultant should have done so. Both documents record as a side effect of using Lamotrigine a risk that the patient may begin to experience thoughts of self-harm or suicide. Mr Scott-Brown was never given that information.

The consultant gave evidence that he was not aware of that particular side effect of Lamotrigine, and that his prescribing practice was informed by the British National Formulary and The Maudsley

Prescribing Guidelines. Neither the online BNF viewable via the NICE website nor the 10th Edition of The Maudsley Guidelines (to which the court was referred) refer to that side effect in their respective entries for Lamotrigine.

Subsequent to the conclusion of the Inquest, I have learned from the Oxleas NHS Foundation Trust that when Mr Scott-Brown was prescribed Lamotrigine, the then current edition of the Maudsley Guidelines was the 13th Edition. The Inquest heard no evidence about the 13th Edition of the Maudsley Guidelines and information therein concerning Lamotrigine.

Quite apart from any issue regarding the consultant’s knowledge about Lamotrigine (and the existence of the 13th Edition of the Maudsley Guidelines) and his not having given Mr Scott-Brown the Trust’s prepared information about the drug and its side effects, I am concerned that two obviously reputable sources of pharmacological information are apparently silent, or have been silent, on a potentially significant side effect of this particular drug.

From a lay perspective, there is apparent potential for harm to patients depending upon which resources a prescriber consults before prescribing Lamotrigine. That potential for harm might be ameliorated were the advice about Lamotrigine consistent across all such resources.

Responses

4 respondents

Oxleas NHS Foundation Trust NHS / Health Body

20 Aug 2020 PDF

Noted

Oxleas NHS Foundation Trust states they no longer have any involvement in the authorship or editing of the Maudsley Prescribing Guidelines since April 2015. (AI summary)

View full response

Dear Mr Longstaff

Re: Viktor John Anthony Scott-Brown, deceased

We write in response to your Regulation 28 Report dated 18 August 2020 and your letter dated 19 August 2020.

Oxleas NHS Foundation Trust no longer has any involvement in the authorship or editing of the Maudsley Prescribing Guidelines. Our last involvement was in April 2015, when the 12th edition was published.

The most recent version, the 13th edition, was published in May 2018, and cited a new team of editors, which did not include Oxleas NHS Foundation Trust.

Oxleas NHS Foundation Trust is therefore not in a position to influence the content of future iterations of the Maudsley Prescribing Guidelines.

We trust that this provides a satisfactory response, but if you have any further queries, please do contact us via oxl-tr.legalservices@nhs.net.

Tees Esk & Wear Valley NHS Foundation Trust NHS / Health Body

25 Aug 2020 PDF

Action Planned

Tees Esk & Wear Valley NHS Foundation Trust is developing a Medication Safety Series document regarding prescribing resources and sources of patient information, aiming to have a draft ready for approval on 24th September 2020 and complete dissemination by 2nd October 2020. (AI summary)

View full response

Dear Mr Longstaff

Re: Viktor John Anthony Scott-Brown Regulation 28 Report

Further to your letter of 25 August 2020, I write to detail the actions the Trust is taking to address the concerns you identified during the inquest into Viktor John Anthony Scott-Brown’s death.

In particular the Trust was to ensure that its prescribers work with reference to the up to date edition of any resource upon which they rely for prescribing guidance.

I would like to reassure you that as an organisation we have taken your concerns seriously. As a consequence we have committed to develop a Medication Safety Series document regarding prescribing resources and sources of patient information. This will be made available to all prescribers. We are aiming to have a draft ready for approval at our Drugs and Therapeutics Committee on 24th September 2020. The final document will then be provided to all prescribers and other relevant staff within the Trust. This is expected to be completed by 2nd October 2020. In addition further communication on this will be provided widely through the Trust Ebulletin. It will also be available on the Trust intranet.

I trust this provides you with the reassurance you required that we are taking appropriate action to address your concerns. However, should you require any further information please do not hesitate to contact me.

National Institute for Health and Care Excellence Other

22 Sep 2020 PDF

Action Planned

NICE has passed the concerns regarding lamotrigine to the BNF publishers and will consider moving a footnote about the risk of suicidal thoughts and behaviour into the recommendation of their guideline on epilepsies, currently being updated. (AI summary)

View full response

Dear Mr Longstaff,

I write in response to your Regulation 28: Report to Prevent Future Deaths, dated 18 August 2020, regarding the tragic death of Viktor John Anthony Scott-Brown.

We have considered the circumstances surrounding Mr Scott-Brown’s death and the concerns raised in the report regarding the content of the British National Formulary (BNF). Namely, that the BNF information regarding lamotrigine should be updated to mention possible risks of self-harm, and suicidal thoughts and behaviour.

Although accessible from the NICE website, the BNF is a joint publication of the British Medical Association and the Royal Pharmaceutical Society. NICE manages the contract for the production of the BNF and BNF for Children (BNFC), but has no role in reviewing their content.

Your concerns have therefore been passed to the BNF publishers, in confidence, for their consideration and action, as appropriate. They have confirmed they will respond to the Regulation 28: Report directly to you, copying NICE into their response.

The concerns in your report have also been considered by NICE’s Centre for Guidelines, with regards to our guideline on epilepsies: diagnosis and management (CG137). This guideline contains the following recommendation and footnote:

1.9.17 Continuation of pharmacological treatment

1.9.17.1 Maintain a high level of vigilance for treatment-emergent adverse effects (for example, bone health issues and neuropsychiatric issues[16]).

[16] Treatment with AEDs is associated with a small risk of suicidal thoughts and behaviour; available data suggest that the increased risk applies to all AEDs and may be seen as early as 1 week after starting treatment.

The guideline is currently in the process of being updated.

Given that the guideline update is not due to publish for some time we will consider the concerns of the coroner’s report – including, the appropriateness of moving the footnote into the recommendation.

BNF Publications

30 Sep 2020 PDF

Action Planned

BNF Publications will add suicidal ideation as a side effect to the lamotrigine monograph and the important safety section of the lamotrigine monograph in the BNF. (AI summary)

View full response

Dear Mr Longstaff, We write in response to your letter to NICE dated 18th August 2020 (ref: 02705-2018). Your letter was forwarded to us as the Publisher of the British National Formulary. We are sorry to hear the sad circumstances surrounding this case. We have reviewed the BNF content for lamotrigine in response to your letter and can confirm that we will add a side-effect of suicidal ideation to the lamotrigine monograph in the BNF. We will also add information on this side-effect to the important safety section of the lamotrigine monograph. This will mean that the risk of suicidal thoughts and behaviour will be highlighted in the lamotrigine monograph in future. We trust that this addresses this important issue

Report sections

Investigation and inquest

On 20th December 2018 I commenced an investigation into the death of Viktor John Anthony SCOTT-BROWN aged 23. The investigation concluded at the end of the inquest on 12th August 2020. The conclusion of the inquest was that the death was a suicide. The medically certified cause of death was:-

I a Hanging

Circumstances of the death

Viktor John Anthony Scott-Brown was found hanging at his home address overnight on the 14th/15th December 2018 and pronounced dead at the scene. There were no suspicious circumstances. He had recently been prescribed Lamotrigine but had not been warned that use of that medication carries a risk of causing thoughts of self harm or suicide, and his taking of that medication was not monitored accordingly. Had he been informed of that risk, he would have sought medical assistance when he began to experience thoughts of self harm and suicide, and it is unlikely he would have taken his life when he did.

Action should be taken

In the case of NICE, that power arises from the BNF being a resource accessible on the NICE website.

In the case of The South London and Maudsley NHS Foundation Trust and the Oxleas NHS Foundation Trust, that power arises from the credited authors and editors of The Maudsley Prescribing Guidelines (10th Edition) being in post within those Trusts respectively.

In the case of Informa Healthcare, that power arises from that corporate entity being the publisher of The Maudsley Prescribing Guidelines.

In the case of the Tees, Esk and Wear Valleys NHS Foundation Trust, that power arises from the Trust being in a position to ensure that its prescribers work with reference to the up to date edition of any resource upon which they rely for prescribing guidance.

Copies sent to

Brown

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Hyponatraemia Inquiry Drug Prescription Documentation

Report details

Reference: 2020-0163
Date of report: 18 August 2020
Coroner: Oliver Longstaff
Coroner area: County Durham and Darlington

Responses identified

Responses identified 4 of 5

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Oct 2020.

Sent to

Informa Healthcare

National Institute for Health and Care Excellence

Oxleas NHS Foundation Trust

South London and Maudsley NHS Foundation Trust

Tees, Esk and Wear Valleys NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.