Danielle Jones
PFD Report
All Responded
Ref: 2025-0542
All 1 response received
· Deadline: 22 Dec 2025
Response Status
Responses
1 of 1
56-Day Deadline
22 Dec 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. Miss Jones had a background of substance abuse, previous and recent (prescription) overdose. Miss Jones self-disclosed overuse of GP prescribed Diazepam on 12th July 2023, 18th April 2024, and 13th June 2024. Miss Jones also reported depleted GP prescribed Zopiclone medication on 4th September 2024.
2. She had a telephone consultation with her GP on 24/2/25 where she disclosed an overdose of her prescription medication and had a further telephone appointment with her GP on 25/2/24 where she repeated the same information.
3. Miss Jones was being supported by Cranstoun Drug & Alcohol Service. Miss Jones attended for an appointment with Cranstoun on 21/2/25 where she confirmed that a recent tablet ingestion was a deliberate overdose attempt. Following that appointment the substance abuse nurse updated the GP practice via email GP updated via email correspondence of well-being concern following intentional overdose. It is unknown whether this communication was known to the GP who spoke to Miss Jones on 24th and 25th February 2025.
4. In any event, Miss Jones self-reported to her GP on both 24/2/25 and 25/2/25 that she had taken an excessive amount of her prescription medication 3 weeks previously. She reported that she had taken but vomited afterwards.
5. Although Miss Jones was signposted to Mental Health Services by her GP, her prescription medications do not appear to have been reviewed and the GP surgery continued to prescribed repeat medications in large amounts at 28 day frequency without any further review subsequent to her appointment on 25/2/25.
6. She was issued with repeat prescriptions on 3 occasions subsequent to her appointment on 24th and 25th February 2025 when she self-disclosed an overdose of prescription medication.
7. On 6/3/25 despite a recent self-reported admitted overdose of prescription medication of
8. On 27/3/25 despite a recent self-reported admitted overdose of prescription medication of Miss Jones was prescribed Amitriptyline , Diazepam lamotrigine mirtazapine pregabalin zopiclone
9. On 28/4/25 despite a recent self-reported admitted overdose of prescription medication of Miss Jones was prescribed
10. Miss Jones died on 13/5/25 from the combined toxic effects of a fatal level of amitriptyline along with an excessive amount of zopiclone.
11. The clinical lead at Cranstoun had previously had discussions with the GP about reducing Miss Jones prescription for zopiclone.
12. No medication review appears to have taken place after Miss Jones self-reported overdose of prescribed medication nor after concerns were raised by Cranstoun.
13. GMC Guidance requires a practitioner to prescribe drugs or treatment including repeat prescriptions, only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs and to keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made.
14. There is no clinical rationale recorded for the continued prescribing of Miss Jones’s repeat medications in terms of managing Miss Jones’s risk of overdose given her recent disclosure e.g. reducing the frequency to 7 days rather than 28 days.
15. There is no evidence of any medication review having taken place after Miss Jones’s disclosure of overdose of prescription medication or prior to her repeat prescriptions being issued on 6/2/25, 27/3/25 or 28/4/25. Her last reported medication review was on 23/8/24.
2. She had a telephone consultation with her GP on 24/2/25 where she disclosed an overdose of her prescription medication and had a further telephone appointment with her GP on 25/2/24 where she repeated the same information.
3. Miss Jones was being supported by Cranstoun Drug & Alcohol Service. Miss Jones attended for an appointment with Cranstoun on 21/2/25 where she confirmed that a recent tablet ingestion was a deliberate overdose attempt. Following that appointment the substance abuse nurse updated the GP practice via email GP updated via email correspondence of well-being concern following intentional overdose. It is unknown whether this communication was known to the GP who spoke to Miss Jones on 24th and 25th February 2025.
4. In any event, Miss Jones self-reported to her GP on both 24/2/25 and 25/2/25 that she had taken an excessive amount of her prescription medication 3 weeks previously. She reported that she had taken but vomited afterwards.
5. Although Miss Jones was signposted to Mental Health Services by her GP, her prescription medications do not appear to have been reviewed and the GP surgery continued to prescribed repeat medications in large amounts at 28 day frequency without any further review subsequent to her appointment on 25/2/25.
6. She was issued with repeat prescriptions on 3 occasions subsequent to her appointment on 24th and 25th February 2025 when she self-disclosed an overdose of prescription medication.
7. On 6/3/25 despite a recent self-reported admitted overdose of prescription medication of
8. On 27/3/25 despite a recent self-reported admitted overdose of prescription medication of Miss Jones was prescribed Amitriptyline , Diazepam lamotrigine mirtazapine pregabalin zopiclone
9. On 28/4/25 despite a recent self-reported admitted overdose of prescription medication of Miss Jones was prescribed
10. Miss Jones died on 13/5/25 from the combined toxic effects of a fatal level of amitriptyline along with an excessive amount of zopiclone.
11. The clinical lead at Cranstoun had previously had discussions with the GP about reducing Miss Jones prescription for zopiclone.
12. No medication review appears to have taken place after Miss Jones self-reported overdose of prescribed medication nor after concerns were raised by Cranstoun.
13. GMC Guidance requires a practitioner to prescribe drugs or treatment including repeat prescriptions, only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs and to keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made.
14. There is no clinical rationale recorded for the continued prescribing of Miss Jones’s repeat medications in terms of managing Miss Jones’s risk of overdose given her recent disclosure e.g. reducing the frequency to 7 days rather than 28 days.
15. There is no evidence of any medication review having taken place after Miss Jones’s disclosure of overdose of prescription medication or prior to her repeat prescriptions being issued on 6/2/25, 27/3/25 or 28/4/25. Her last reported medication review was on 23/8/24.
Responses
The practice plans to amend its Prescribing Policy by January 2026 to include clear guidance on medication quantities and reducing amounts if there is a self-harm risk. It will also amend its risk assessment template to include a mental health medication review code and discussions on stockpiled medication, and will re-launch this policy and share learning with clinicians.
AI summary
View full response
Lyndon Primary Care Centre Lower Lyndon West Bromwich West Midlands B71 4HJ Tel: 0121 553 0385 Great Bridge Health Centre Unit 18 Great Bridge Centre, Great Bridge Street West Bromwich West Midlands Tel: 0121 612 3650 Oakham Surgery 213 Regent Road Tividale West Midlands B69 1RZ Tel: 01384 458 968 Regis Medical Centre Darby Street Rowley Regis West Midlands B65 0BA Tel: 0121 559 3957 Mace Street Clinic Mace Street Cradley Heath West Midlands B64 6HP Tel: 01384 354 653 Whiteheath Medic Centre Badsey Road Oldbury West Midlands B69 1EJ Tel: 0121 612 270 Response to Regulation 28: Report to Prevent Future Deaths Coroner: Mrs Joanne Lees, Area Coroner for The Black Country Deceased: Danielle Monique Christina JONES Date:
22.12.2025 Timeline taken from patient record:
23.8.24 Medication review carried out with patient. No suicidal thoughts or thoughts of self harm. Mood ok with meds. Continue current repeat medication
24.2.25 Email received from Cranstoun to inform GP that patient had informed them she had taken an intentional overdose of her prescribed medication, had written notes to family members then changed her mind and made herself vomit.
4.2.25 1 month supply of repeat meds issued
24.2.25 Telephone consultation with Dr . Discussed overdose which patient stated had happened 3 weeks ago. The patient regretted the decision and made herself vomit immediately afterwards. Denies any current thoughts of self- harm. She stated she was currently living with her grandparents. Danielle was offered a face-to-face appointment on the same day, but stated she was unable to attend in person on the same day, so booked for the following day. The current details and information Danielle gave of the overdose were not consistent with the email received from Cranstoun. It is standard practice to complete the risk assessment contemporaneously with the patient based upon current mood, whilst mindful of previous information. This is to ensure an accurate and appropriate risk assessment is made at the time of the conversation.
25.2.25 Did Not Attend the face-to-face appointment
25.2.25 Follow up telephone call made by Dr Danielle stated she had not attended because she could not find her bus pass and credit on her phone had run out. Denies any current/active plans to self-harm and feels mental health is currently stable and managing. Crisis team number given-if thoughts of self-harm 999/A & E.
6.3.25 1 month supply of meds issued
27.3.25 1 month supply of repeat meds issued
28.4.25 1 month supply of repeat meds issued
13.5.25 Ambulance report received – death confirmed
14.5.25 Coroners office confirmed police had reported death
Lyndon Primary Care Centre Lower Lyndon West Bromwich West Midlands B71 4HJ Tel: 0121 553 0385 Great Bridge Health Centre Unit 18 Great Bridge Centre, Great Bridge Street West Bromwich West Midlands Tel: 0121 612 3650 Oakham Surgery 213 Regent Road Tividale West Midlands B69 1RZ Tel: 01384 458 968 Regis Medical Centre Darby Street Rowley Regis West Midlands B65 0BA Tel: 0121 559 3957 Mace Street Clinic Mace Street Cradley Heath West Midlands B64 6HP Tel: 01384 354 653 Whiteheath Medic Centre Badsey Road Oldbury West Midlands B69 1EJ Tel: 0121 612 270 YHP PCN aims to treat individuals presenting with acts of self-harm in line with NICE Quality Standards 34 regarding Self Harm. The principle underpinning this is pro-active follow up to prevent patient harm. Patients should be offered follow up with a doctor or physicians associate of their choice and offered continuity of care. The YHP clinical guideline regarding follow up of self-harm was launched in January 2014. The updated QS34 includes a suggestion that if a person presents to a service with self-harm and ongoing risk that organisation should pro-actively follow that person up within 48 hours. Based upon the above NICE guidance, YHP currently has a Standard Operating Procedure in place for our administrative teams to highlight any clinical correspondence received with any mention of attempted suicide or self-harm and forward to a GP for action. In this case an email was received from Cranstoun (local drug and alcohol team) informing us of recent overdose and concerns. This was immediately passed to the duty GP who arranged a same day GP telephone assessment. As detailed in the timeline, a Face-to-Face appointment for the same day was also offered, but declined by Danielle. However, a face-to-face appointment for the following day was booked. When Danielle did not attend this appointment, a follow up call was placed by the Dr Ananthram. This is in line with the Standard Operating Procedure. We acknowledge that although a risk assessment was carried out regarding current and future suicidal intent and plans as part of the same day appointment, the issue of medication was not specifically addressed. This issue has been discussed with the individual clinician involved and the system changes below will ensure that all clinicians will be aware of the need to review medication in similar cases in the future. These changes have will be made on 1st January 2026. This has been communicated to the clinicians via the monthly YHP Clinical Update Newsletter and in team meetings. We have undertaken an annual audit of compliance with proactive follow up following self-harm since
2014. The results of the audits have provided assurance that the process of proactive follow up is being followed by our clinicians. QS 34 states people who have self-harmed have an initial assessment of physical health, mental state, safeguarding concerns, social circumstances and immediate concerns about their safety. However, it does not specifically state they require a medication review. We have a self-harm risk assessment template built into our clinical system to aid clinicians in discussing this with patients. (see image below)
Lyndon Primary Care Centre Lower Lyndon West Bromwich West Midlands B71 4HJ Tel: 0121 553 0385 Great Bridge Health Centre Unit 18 Great Bridge Centre, Great Bridge Street West Bromwich West Midlands Tel: 0121 612 3650 Oakham Surgery 213 Regent Road Tividale West Midlands B69 1RZ Tel: 01384 458 968 Regis Medical Centre Darby Street Rowley Regis West Midlands B65 0BA Tel: 0121 559 3957 Mace Street Clinic Mace Street Cradley Heath West Midlands B64 6HP Tel: 01384 354 653 Whiteheath Medic Centre Badsey Road Oldbury West Midlands B69 1EJ Tel: 0121 612 270 We had not specifically included medication review as part of this template. We will amend our follow up policy to specifically mention the need for medication review at the time of pro-active follow up, and in particular to consider reducing the amount of medication per prescription if there is any ongoing risk of further self-harm and especially with high-risk medications. We will amend our risk assessment template to include a mental health medication review code and free text advice regarding the following with a free text box to record discussions. Do you have any stockpiled medications? Do you feel safe with your current medication quantity? Would reducing the number of medications per prescription reduce the risk of future harm?
Lyndon Primary Care Centre Lower Lyndon West Bromwich West Midlands B71 4HJ Tel: 0121 553 0385 Great Bridge Health Centre Unit 18 Great Bridge Centre, Great Bridge Street West Bromwich West Midlands Tel: 0121 612 3650 Oakham Surgery 213 Regent Road Tividale West Midlands B69 1RZ Tel: 01384 458 968 Regis Medical Centre Darby Street Rowley Regis West Midlands B65 0BA Tel: 0121 559 3957 Mace Street Clinic Mace Street Cradley Heath West Midlands B64 6HP Tel: 01384 354 653 Whiteheath Medic Centre Badsey Road Oldbury West Midlands B69 1EJ Tel: 0121 612 270 Can a safety plan be put in place e.g. can a friend or family member supervise your medications? We will re-launch this amended policy in January 2026 with our clinicians and add the recording of medic ation review and recording of consideration of reducing amount of medication on each issue as part of the annual audit program. The learning from this event will be shared with clinicians via our monthly clinical update but also added to the agenda of our next face to face protected learning event for our GP’s in the new year. This learning has also been shared with our Acute Trust patient safety team colleagues for wider dissemination of learning. We will continue to audit the proactive follow up of self-harm annually but include specific data on whether a medication review was completed and discussion was had regarding amounts of medications prescribed. Clinical Quality Lead Your Health Partnership PCN
22.12.2025 Timeline taken from patient record:
23.8.24 Medication review carried out with patient. No suicidal thoughts or thoughts of self harm. Mood ok with meds. Continue current repeat medication
24.2.25 Email received from Cranstoun to inform GP that patient had informed them she had taken an intentional overdose of her prescribed medication, had written notes to family members then changed her mind and made herself vomit.
4.2.25 1 month supply of repeat meds issued
24.2.25 Telephone consultation with Dr . Discussed overdose which patient stated had happened 3 weeks ago. The patient regretted the decision and made herself vomit immediately afterwards. Denies any current thoughts of self- harm. She stated she was currently living with her grandparents. Danielle was offered a face-to-face appointment on the same day, but stated she was unable to attend in person on the same day, so booked for the following day. The current details and information Danielle gave of the overdose were not consistent with the email received from Cranstoun. It is standard practice to complete the risk assessment contemporaneously with the patient based upon current mood, whilst mindful of previous information. This is to ensure an accurate and appropriate risk assessment is made at the time of the conversation.
25.2.25 Did Not Attend the face-to-face appointment
25.2.25 Follow up telephone call made by Dr Danielle stated she had not attended because she could not find her bus pass and credit on her phone had run out. Denies any current/active plans to self-harm and feels mental health is currently stable and managing. Crisis team number given-if thoughts of self-harm 999/A & E.
6.3.25 1 month supply of meds issued
27.3.25 1 month supply of repeat meds issued
28.4.25 1 month supply of repeat meds issued
13.5.25 Ambulance report received – death confirmed
14.5.25 Coroners office confirmed police had reported death
Lyndon Primary Care Centre Lower Lyndon West Bromwich West Midlands B71 4HJ Tel: 0121 553 0385 Great Bridge Health Centre Unit 18 Great Bridge Centre, Great Bridge Street West Bromwich West Midlands Tel: 0121 612 3650 Oakham Surgery 213 Regent Road Tividale West Midlands B69 1RZ Tel: 01384 458 968 Regis Medical Centre Darby Street Rowley Regis West Midlands B65 0BA Tel: 0121 559 3957 Mace Street Clinic Mace Street Cradley Heath West Midlands B64 6HP Tel: 01384 354 653 Whiteheath Medic Centre Badsey Road Oldbury West Midlands B69 1EJ Tel: 0121 612 270 YHP PCN aims to treat individuals presenting with acts of self-harm in line with NICE Quality Standards 34 regarding Self Harm. The principle underpinning this is pro-active follow up to prevent patient harm. Patients should be offered follow up with a doctor or physicians associate of their choice and offered continuity of care. The YHP clinical guideline regarding follow up of self-harm was launched in January 2014. The updated QS34 includes a suggestion that if a person presents to a service with self-harm and ongoing risk that organisation should pro-actively follow that person up within 48 hours. Based upon the above NICE guidance, YHP currently has a Standard Operating Procedure in place for our administrative teams to highlight any clinical correspondence received with any mention of attempted suicide or self-harm and forward to a GP for action. In this case an email was received from Cranstoun (local drug and alcohol team) informing us of recent overdose and concerns. This was immediately passed to the duty GP who arranged a same day GP telephone assessment. As detailed in the timeline, a Face-to-Face appointment for the same day was also offered, but declined by Danielle. However, a face-to-face appointment for the following day was booked. When Danielle did not attend this appointment, a follow up call was placed by the Dr Ananthram. This is in line with the Standard Operating Procedure. We acknowledge that although a risk assessment was carried out regarding current and future suicidal intent and plans as part of the same day appointment, the issue of medication was not specifically addressed. This issue has been discussed with the individual clinician involved and the system changes below will ensure that all clinicians will be aware of the need to review medication in similar cases in the future. These changes have will be made on 1st January 2026. This has been communicated to the clinicians via the monthly YHP Clinical Update Newsletter and in team meetings. We have undertaken an annual audit of compliance with proactive follow up following self-harm since
2014. The results of the audits have provided assurance that the process of proactive follow up is being followed by our clinicians. QS 34 states people who have self-harmed have an initial assessment of physical health, mental state, safeguarding concerns, social circumstances and immediate concerns about their safety. However, it does not specifically state they require a medication review. We have a self-harm risk assessment template built into our clinical system to aid clinicians in discussing this with patients. (see image below)
Lyndon Primary Care Centre Lower Lyndon West Bromwich West Midlands B71 4HJ Tel: 0121 553 0385 Great Bridge Health Centre Unit 18 Great Bridge Centre, Great Bridge Street West Bromwich West Midlands Tel: 0121 612 3650 Oakham Surgery 213 Regent Road Tividale West Midlands B69 1RZ Tel: 01384 458 968 Regis Medical Centre Darby Street Rowley Regis West Midlands B65 0BA Tel: 0121 559 3957 Mace Street Clinic Mace Street Cradley Heath West Midlands B64 6HP Tel: 01384 354 653 Whiteheath Medic Centre Badsey Road Oldbury West Midlands B69 1EJ Tel: 0121 612 270 We had not specifically included medication review as part of this template. We will amend our follow up policy to specifically mention the need for medication review at the time of pro-active follow up, and in particular to consider reducing the amount of medication per prescription if there is any ongoing risk of further self-harm and especially with high-risk medications. We will amend our risk assessment template to include a mental health medication review code and free text advice regarding the following with a free text box to record discussions. Do you have any stockpiled medications? Do you feel safe with your current medication quantity? Would reducing the number of medications per prescription reduce the risk of future harm?
Lyndon Primary Care Centre Lower Lyndon West Bromwich West Midlands B71 4HJ Tel: 0121 553 0385 Great Bridge Health Centre Unit 18 Great Bridge Centre, Great Bridge Street West Bromwich West Midlands Tel: 0121 612 3650 Oakham Surgery 213 Regent Road Tividale West Midlands B69 1RZ Tel: 01384 458 968 Regis Medical Centre Darby Street Rowley Regis West Midlands B65 0BA Tel: 0121 559 3957 Mace Street Clinic Mace Street Cradley Heath West Midlands B64 6HP Tel: 01384 354 653 Whiteheath Medic Centre Badsey Road Oldbury West Midlands B69 1EJ Tel: 0121 612 270 Can a safety plan be put in place e.g. can a friend or family member supervise your medications? We will re-launch this amended policy in January 2026 with our clinicians and add the recording of medic ation review and recording of consideration of reducing amount of medication on each issue as part of the annual audit program. The learning from this event will be shared with clinicians via our monthly clinical update but also added to the agenda of our next face to face protected learning event for our GP’s in the new year. This learning has also been shared with our Acute Trust patient safety team colleagues for wider dissemination of learning. We will continue to audit the proactive follow up of self-harm annually but include specific data on whether a medication review was completed and discussion was had regarding amounts of medications prescribed. Clinical Quality Lead Your Health Partnership PCN
Report Sections
Investigation and Inquest
On 14/05/25 I commenced an investigation into the death of Danielle Monique Christina JONES. The investigation concluded at the end of the inquest on 1/10/25.
The medical cause for the death of Danielle Jones was as follows;
1a Multidrug Toxicity II History of Depression, Drug Abuse
The conclusion at inquest was Suicide.
The medical cause for the death of Danielle Jones was as follows;
1a Multidrug Toxicity II History of Depression, Drug Abuse
The conclusion at inquest was Suicide.
Circumstances of the Death
On 13/5/25 Miss Danielle JONES was found unresponsive at her home address and confirmed as deceased by attending paramedics. She was found in the bathroom by her partner. Miss Jones had a background of mental health problems, substance misuse, previous and recent (prescription) drug overdose.
Post-mortem toxicology tests found evidence of High levels of amitriptyline along with excess zopiclone and recent substantial cocaine use. The Pathologist concluded she died from multi drug toxicity.
The amitriptyline level was within the fatal range. The level of zopiclone was well above that expected from therapeutic dosage.
I found she died from the combined toxic effects of a fatal level of amitriptyline along with an excessive amount of zopiclone.
Post-mortem toxicology tests found evidence of High levels of amitriptyline along with excess zopiclone and recent substantial cocaine use. The Pathologist concluded she died from multi drug toxicity.
The amitriptyline level was within the fatal range. The level of zopiclone was well above that expected from therapeutic dosage.
I found she died from the combined toxic effects of a fatal level of amitriptyline along with an excessive amount of zopiclone.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.