Source · Prevention of Future Deaths
George Stone
Ref: 2014-0379
Date: 20 Aug 2014
Coroner: David Horsley
Area: Portsmouth & South East Hampshire
Responses identified: 0 / 1
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National guidelines for antidepressant warnings, specifically for Venlafaxine, fail to include the rare but severe risk of seizures, potentially leaving patients uninformed about a critical side effect.
Date
20 Aug 2014
56-day deadline
15 Oct 2014
Responses identified
0 of 1
Coroner's concerns
National guidelines for antidepressant warnings, specifically for Venlafaxine, fail to include the rare but severe risk of seizures, potentially leaving patients uninformed about a critical side effect.
View full coroner's concerns
I was told in evidence at the Inquest that a side effect of Venlafaxine and similar antidepressants is seizures and that although this is rare, these seizures can be very severe - as was the case with George Stone. I was also told that the NPSA issues national guidelines for the warnings practitioners must give their patients who are prescribed these sorts of antidepressants but the risk of patients suffering a severe seizure is not included in the guidelines at the present time. 2
Report sections
Investigation and inquest
On 22nd November 2012 I commenced an investigation into the death of George Douglas Stone, aged 37. The investigation concluded at the end of the inquest on 16th August 2013. The conclusion of the inquest was that the medical cause of George Stone's death was Yew Tree Leaf Intoxication and he had taken his own life whilst suffering from a long term depressive disorder.
Circumstances of the death
George Stone suffered from long term depressive illness. In August 2012 he was prescribed Venlafaxine which caused him to suffer a grand mal seizure on 6th September 2012. This in turn led to an exacerbation of his depressive illness and he ended his own life on 19th November 2012.
Action should be taken
In my opinion action should be taken to prevent future deaths by consideration of changes to the guidelines for prescribing Venlafaxine and similar antidepressants to include a specific warning to patients about the risks of their suffering severe seizures whilst taking these medications. I believe your organisation has the power to take such action.
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Report details
- Reference
- 2014-0379
- Date of report
- 20 August 2014
- Coroner
- David Horsley
- Coroner area
- Portsmouth & South East Hampshire
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Oct 2014.
Sent to
- National Patient Safety Agency