Source · Prevention of Future Deaths

Dafydd Watts

Ref: 2014-0194 Date: 29 Apr 2014 Coroner: T G Moore Area: Avon Responses identified: 0 / 2 View PDF

Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences associated with medication.

Date 29 Apr 2014
56-day deadline 28 Jun 2014
Responses identified 0 of 2
Alcohol, drug and medication related deaths

Coroner's concerns

AI summary
Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences associated with medication.
View full coroner's concerns
Although the evidence suggests that this is only the fourth such death documented it appears that the possibility (albeit remote) of such an occurrence is not drawn to physicians attention in the drug literature or in the BNF entry:

Report sections

Investigation and inquest
On commenced an investigation into the death of Dafydd Rhys WATTS, Aged 34. The investigation concluded at the end of the inquest on 14th March 2014. The conclusion of the inquest was; la Pericarditis Ib Drug reaction with eosinophilia and systemic symptoms syndrome (DRESS) Ic Epilepsy treated with levetiracetam Conclusion; Dafyyd Watts died suddenly of pericarditis following an unrecognised and exceptionally rare drug reaction to his necessary anti-epileptic treatment
Circumstances of the death
The deceased died of eosinophilic pericarditis and DRESS syndrome due to Levetiracetam He had previously been prescribed Carbamazepine but suffered pulmonary eosinophilia. He ceased this treatment and started Levetiracetam_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action.

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Report details

Reference
2014-0194
Date of report
29 April 2014
Coroner
T G Moore
Coroner area
Avon

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 28 Jun 2014.

Sent to

British National Formulary
UCB Pharma

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