Source · Prevention of Future Deaths

Michael Anthony

Ref: 2014-0161 Date: 9 Apr 2014 Coroner: Andrew Harris Area: London (Inner South) 1 response identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner identified high levels of Gabapentin in a diabetic patient, a drug generally not prescribed to diabetics due to severe reaction risks. Concerns were raised as the GP did not explain the rationale for this prescription.

Date 9 Apr 2014

56-day deadline 4 Jun 2014 est. estimated from the report date

Responses identified 1 of 2

Community health care and emergency services related deaths

Coroner's concerns

AI summary

The coroner identified high levels of Gabapentin in a diabetic patient, a drug generally not prescribed to diabetics due to severe reaction risks. Concerns were raised as the GP did not explain the rationale for this prescription.

Responses

1 respondent

Guys St Thomas NHS Trust

NHS Trust

Letter dated 6 May 2014 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The Trust requested full disclosure of the toxicologist's report. • The Trust requested and received a review from the regional drug information service. • The Trust stated it had made necessary changes by building the review into its daily practice.

View full response

Dear Mr John Thompson Re: MR MCHAEL ANTHONY (DECEASED) Date of Birth: 15-05-1948 NHS No] Address Many thanks for your letter of 10lh April last sent to both myself and in relation to the above deceased: note and acknowledge receipt of the Regulation 28 report to prevent future deaths on the above addressed to myself and have asked for full disclosure by email to the coroner's office of the toxicologists report: In the meantime, we have asked for a review from the regional drug information service at Guy's. This is attached below and forms part of our reflection, learning and response_ We have spoken to Clinical Lead for Diabetes and Endocrinology at Guy's and St, Thomas' and Clinical Director for ihe Clinical Academic Grouping of Diabetes and Endocrinology in King's Health Partner, who does not recognise this particular risk and in his own extensive experience has not seen it and have conferred: We have used this drug over many years_ It is licensed for the use of the treatment of syndrome in diabetics have never had any problems such as described in the case_ We both note the comments by the Toxicologist, We have made the necessary changes by building this review into our day to practice. If there is any further comments to be added on receipt of the disclosure requested above, we will reply but at present we would ask that this letter serves as our conclusion and formal reply to the letter received from you on behalf of the Chief Coroner.

Report sections

Investigation and inquest

On 14.05.13 [ opened an inquest into the death of Michael Anthony, aged 64, who died on 8th May 2013. The inquest was concluded on 26" March 2014. The conclusion of the inquest was given in a narrative: Mr Anthony was found dead in his flat on &h May 2013. There were no suspicious circumstances: He died diabetic ketoacidotic coma. He a very high Gabapentin level in his blood, which along with a fatty liver from Hepatitis B andlor diabetes, contributed to his death. It was not possible to conclude whether the ketoacidosis was also caused by a reaction to Gabapentin.

Circumstances of the death

The Gabapentin level was five times normal therapeutic level. It was not determined why this level was so high. His ketonuria was reported by the toxicologist as either being due to diabetic coma (shortage of insulin) andlor a reaction to the drug Gabapentin. The toxicologist reported that Gabapentin was usually not prescribed in diabetics_ as some individuals developed a severe reaction which precipitated diabetic coma: The court read the evidence of the GP, who did not refer to the reasons for prescribing Gabapentin and did not call the consultant physician, but heard it was for pain relief:

Action should be taken

The doctors are asked to review the prescribing of this and its consider whether it is appropriate to update their indications and prescribing knowledge and practice_

Similar PFD reports

Shared signals

Report details

Reference: 2014-0161
Date of report: 9 April 2014
Coroner: Andrew Harris
Coroner area: London (Inner South)

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Jun 2014 (estimated from the report date).

Sent to

Guy’s Hospital

Princess Street Practice

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.